McSweeney & Ricci Insurance Agency. Inc.

Watercraft Insurance - Online Quote Form

Name and Address

Your Name
Street Address
Additional Info (Apt #, etc.)

City		State		Zip (Required)
Email

Day Phone

Evening Phone

Fax Number

How would you prefer that we reply to you?

Current insurance carrier

How Long?

yrs

Policy Expiration Date

Social Security Number

Drivers License Number

Number of years experience

Member of any boating association

Purchase price:

Loss Payee:

Loss Payee (if applicable)

Name
Address

City

State

Zip

Balance Due:

Has Insurance ever been declined?

If yes, explain

List and detail any losses or claims

Watercraft Information

Year

Length

Model

Builder

Hull Identification Number

Name of Boat

Hull Type

Hull Material

Engine Information

Engine(s)

Year

Manufacturer

How many engines?

HP each

Max Speed (MPH)

Engine(s) Serial Number

Trailer Information

Year

Length

Manufacturer

Serial #

Tender Information

Year

Length

Manufacturer

Serial #

Tender's Motor

Year

Length

Manufacturer

Serial #

Equipment Information

Loran?		Radar?		Halon?
GPS?		Depth Finder?		VHF?

Other

Navigation

Coastal Waters?

Inland Waters?

Specify Waters

Will Vessel be laid up?:

Where?

Chartered?

Ever used for water skiing?

If watercraft is in excess of 24 feet, is it ever transported over land?

How many miles?

Coverage Desired

Effective Period From

	Values	Deductible
Hull and Machinery
Outboard Motor
Equipment
Tender and its Motor
Trailer
Liability
Medical Payments
Overland Transp. (miles)
Uninsured Boaters
Personal Effects
Assistance/Towing