Quote Request
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Owner Information
Salutation
Name*
Address*
City*
State*
Zip Code*
Phone*
Best Time to Call
Home Work
Work Phone
Fax
Email Address*
Type of Ownership*
If partnership, number of partners
Current Insurer
Expiration Date
Premium
Vessel Information
Type
If "Other" is selected, please describe
Construction:
Fiberglass Aluminum
Other construction - please describe

Make/Builder*
Model
Year
Length
Last Survey
Survey Type
Maximum Speed
Purchase Year
Purchase Price
Engine Information
Engine(s)
Manufacturer
Model Year
HP (each)
Engine Type
Fuel Type
Safety Equipment
Automatic Fire Suppression System Radar Carbon Monoxide Detector
Gas Fume Detector Anti-Theft Other
Dinghy Information
Dinghy Make
Length
Model Year
Dinghy Engine Make
HP
Year
Use of Vessel
Principal Mooring/Storage Address
Street
City
State
Zip Code
County
Seasonal Use?
Yes No
Lay Up Location:
City
State
Lay Up Dates (Month/Day)
through (Month/Day)
Lay Up Mode
Hauled Afloat Afloat with bubbler
Navigation Area
Other Navigation Area
Vessel Use
Personal/Pleasure Primary Residence Chartered How Many/Year?
Commercial Use (Explain in Comments) Paid Crew/Captain How Many?
Scuba Diving Raced
Desired Coverage (indicate dollar amount)
Boat (Hull, Machinery and Equipment)
Deductible
1%2%3%
Other % or $ Amount
Liability (P & I)
$100,000 $300,000 $500,000
$1 Million Other Liability Amount

Personal Property
Medical Payments
Fishing Gear
Trailer
Dinghy & Dinghy Engine
Towing
Describe any other coverage desired
Amount
Note: We automatically include coverage for Uninsured Boater and Fuel Spill Liability.
Principal Operator
Name
Date Of Birth
Homeowner MarriedSingle Occupation
Boating Courses
USPS USCGA Other If licensed captain, indicate rating
Boat Ownership Yrs.
Boating Experience Yrs.
Prior Owned Vessels
Make
Length
Year Purchased
Year Sold
Make
Length
Year Purchased
Year Sold
Boat Insurance History
Number of claims in last 5 years?
Please provide date, dollar amount and detail below.
In the past five years, have you had boat insurance cancelled or renewal refused,
other than for nonpayment of premium, or because the insurer withdrew from the market?

YesNo
Please provide detail below.
Motor Vehicle Driving Record - past 3 years
In the past 36 months, how many violations/at-fault accidents have you had?
For each incident, please provide the approximate date (mm/yy) and indicate either at-fault accident or the type of violation:
Additional Operator(s)
Name
Married Single
Relationship
Date of Birth
Yrs. Exp.
In the past 36 months, how many violations/at-fault accidents has operator had?
For each incident, please provide the approximate date (mm/yy) and indicate either at-fault accident or the type of violation:
Name
Married Single
Relationship
Date of Birth
Yrs. Exp.
In the past 36 months, how many violations/at-fault accidents has operator had?
For each incident, please provide the approximate date (mm/yy) and indicate either at-fault accident or the type of violation:
How did you learn about Norman-Spencer Marine?
Referral from a current client Received a mailing Other
Comments
Important notice! Certain of our insurers require a consumer report check in connection with rating. If you wish that we not quote with such companies, please so indicate in Comments below.

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