ACE Recreational Marine Insurance®
Quote Request Form
Red text indicates questions for which responses may not be required to obtain a quote.
AGENCY / PRODUCER INFORMATION
AGENCY NAME
PRODUCER CODE
CONTACT NAME
PHONE NUMBER
APPLICANT / CLIENT INFORMATION
REQUESTED COVERAGE DATE
SOURCE OF BUSINESS
Applicant
PHONE NUMBER
POLICY TO BE ISSUED IN THE NAME OF
EMAIL
MARITAL STATUS
HOME OWNERSHIP/RESIDENCE STATUS
SELECT ONE
SELECT ONE
PRIMARY OWNER’S OCCUPATION
RESIDENCE ADDRESS
CITY
STATE
MULTIPLE UNRELATED OWNERS
Yes
FAX #
Broker
PRIMARY OWNER’S EMPLOYER OR NAME OF OWNED BUSINESS
ZIP
LOSSES IN LAST FIVE (5) YEARS
No
Yes
IF YES TO LOSSES IN LAST FIVE (5) YEARS, PROVIDE DATE & DESCRIPTION
No
OWNER / OPERATOR INFORMATION
DATE OF BIRTH
MM/DD/YYYY
PRIMARY OPERATOR’S NAME
#YRS
BOATS
OWNED
MVR
POINTS
PREVIOUSLY OWNED BOATS
(LENGTH / MAKE / MODEL)
BOATING COURSES
Yes
OPERATOR
No
VESSEL & EQUIPMENT INFORMATION
LENGTH
(FEET)
VESSEL TYPE
MAX SPEED
(MPH)
CHARTER OR COMMERCIAL USE
SELECT ONE
LAY UP PERIOD (VESSELS < 27 FT)
From:
(mm/dd)
YEAR BUILT
To:
Yes
LAY-UP TYPE
(mm/dd)
No
SAFETY EQUIPMENT
SELECT ONE
BUILDER/MANUFACTURER
IF YES, DESCRIBE (INCLUDE CHARTER TYPE AND #
OF CHARTER DAYS ANNUALLY)
Built-in Fire Extinguishing System
MODEL NAME
HULL MATERIAL
SELECT ONE
PURCHASE PRICE
PURCHASE DATE
(mm/dd/yyyy)
TOTAL # OF
PAID CREW
$
MOORING TYPE
STORAGE/MOORING
(CITY/STATE/ZIP)
SELECT ONE
NAVIGATION AREA:
ENGINE INFORMATION
ENGINE TYPE
FUEL TYPE
SELECT ONE
SELECT ONE
# OF ENGINE(S)
MANUFACTURER
YEAR BUILT
ENGINE HORSEPOWER
/ EACH
INSURING AMOUNTS
VESSEL & ENGINE(S)
DEDUCTIBLE
LIABILITY
$
SELECT ONE
$SELECT ONE
OPTIONAL COVERAGES
TRAILER
TENDER (IF YACHTSMAN®/BOATSMAN® POLICY TYPE, TENDERS < 17 FEET LONG WITH MOTOR < 40 HP ARE SUBJECT TO $250 DEDUCTIBLE AT NO CHARGE)
$
$
Policies issued by ACE American Insurance Co., ACE Fire Underwriters Insurance Co., and Insurance
Company of North America – ACE Group companies that are rated A++ (Superior) by A.M. Best Company
and AA by Standard & Poor’s. Company ratings as of November 1, 2015.
© Copyright 2015 ACE Private Risk Services®. All rights reserved. RM-617144c-1115