Pleasure Boat Application Name * Required First Last Business NameAddress * 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 * RequiredFaxEmail * Required Quote InformationOccupation(s)Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY Years Boating ExperienceYears Boat OwnedBoating Certificates/LicensesAny Claims in last 5 yearsPrior Boats Owned – Type, Size, Years OwnedMost RecentPreviousPreviousPreviousPreviousCurrent BoatHullChoose OneSailPowerPurchase PriceDate of Survey (if applicable)MakeModelYearLengthSpeedConstructionYear PurchasedEngineMakeModelYearHorsepowerEngine 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 AreaMooring LocationIf laid up part of the yearWhen to whenWherePaid Crew Yes No Coverage RequestHull and Machinery LimitDeductibleP&I Liability LimitChoose One$100,000$300,000$500,000$1,000,000Current Insurance CompanyExpiration DateCurrent PremiumExtended 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
