Insurance Services of Pompano Beach, Inc.

            101 North Riverside Dr., #123, Pompano Beach, FL 33062

                       (954) 767-9880        FAX: (954) 767-9884

                         E-mail Address:  donna@insuremyboat.net

 

Personal Information

 

Owner:

Address:

Home Phone: Work Phone: Fax

Date of birth: E-Mail:

 

Watercraft Information

 

TYPE OF VESSEL: Cruiser/Motor Yacht    Sport Fish    Sailboat

                           Center Console    Open Fishing    Performance

Year: Length: Manufacturer:

Model: Material: Beam:

Weight: Purchase Price:

Purchase Date:

Date of last survey

In water     Out of water

 

Machinery

 

Gas Diesel Manufacturer Model
No. of Engines H.P. each

Type of drive: IB OB IO Cruise speed Max speed

 

Watercraft Equipment

 

GPS/SATNAV/Loran               Radar                       Fume Detector

VHF/Ship to Shore                Chart Plotter            Autopilot

Depth Finder                        Halon/CO2               Generator

Additional equipment

 

Tender/Dinghy Information

 

Year Length Manufacturer Value


Year of engine Engine Manufacturer

Value of engine

 

Navigation & Storage Information

 

Location of vessel

Layup period – From to     Ashore    Afloat

 

Operator Information

 

Years boating experience Previous owned vessels

Total years ownership Boating courses: USPS USCG

Captain’s license

Other

Is vessel chartered

Do you require captain & crew coverage

Any driving tickets in last (3) years

Any prior claims If yes, please explain

 

Hull Value requested Deductible

Liability limit requested