Pleasure Boat Application Name * Required First Last Business Name Address * Required Street Address Address Line 2 City Choose OneAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone * RequiredFax Email * Required Quote InformationOccupation(s) Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY Years Boating Experience Years Boat Owned Boating Certificates/LicensesAny Claims in last 5 yearsPrior Boats Owned – Type, Size, Years OwnedMost Recent Previous Previous Previous Previous Current BoatHullChoose OneSailPowerPurchase Price Date of Survey (if applicable) Make Model Year Length Speed Construction Year Purchased EngineMake Model Year Horsepower Engine TypeChoose OneInboardOutboardInboard/OutboardOtherEngine FuelChoose OneGasDieselOtherNumber of EnginesChoose OneSingleTwinOtherEquipmentBoat Equipment EPIRB Depth Finder Fume Detector VHF Radar Automatic Halon/CO2 GPS Loran Chartplotter Other EquipmentBoat UsageTypes of Use Pleasure Charter Racing Commercial Navigation Area Mooring Location If laid up part of the yearWhen to when Where Paid Crew Yes No Coverage RequestHull and Machinery Limit Deductible P&I Liability LimitChoose One$100,000$300,000$500,000$1,000,000Current Insurance Company Expiration Date Current Premium Extended Navigation Details, Remarks, Other Coverage, and Loss DetailsFor the AgencyDo you have a specific agent at Smithwick and Mariners you are familiar with? Yes No If yes, please provide agent's name. Do you have a specific office location you prefer to work with?Choose OneNo preferenceFalmouth, MEKennebunk, MESouth Hampton, NHNew Bedford, MA Δ
