Orange Insurance LLC
206.774.7867 [ Office ]
877.288.6103 [ Toll Free ]
206.774.2076 [ Fax ]
ron@insuredbyorange.com [ Email ]
www.insuredbyorange.com [ Web ]
Watercraft / ATV Insurance Questionnaire
 Please fill out this form (type, re-save and email it back if possible) to the best of your knowledge and
ability and then we can get on the phone to go over any questions. (You can “TAB” over to get from question
to question.)
{ Contact Information }
Name:
Address:
Address 2 (if applicable):
Home #:
Cell #:
Work #:
Fax #:
County:
City/State/Zip:
How Long at This Address:
Email:
Requested Time to Call or Email:
{ Watercraft/ATV & Trailer Information }
WATERCRAFT/ATV (Answer Where Applicable):
VIN#:
Hull # (if applicable):
Year:
Make:
Model:
Length:
Engine Size (HP):
Engine Brand:
Fuel (Gasoline, Diesel or Battery):
Fuel Tank (Fiberglass or Metal):
Maximum Speed:
Odometer (approx. hours):
Type of Power:
Inboard
Outboard
Inboard/Outboard
Waterjet
Sail
Type of Hull:
Cabin Cruiser
Open Cockpit
Sailboat
Pontoon
Bass/Fishing
Personal Watercraft
Ski
Hull Material (Fiberglass, Aluminum, Wood, etc.) (if applicable):
Hull Design:
Flat
Round
Vee
Catamaran
Continued on the next page…
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Orange Insurance LLC
206.774.7867 [ Office ]
877.288.6103 [ Toll Free ]
206.774.2076 [ Fax ]
ron@insuredbyorange.com [ Email ]
www.insuredbyorange.com [ Web ]
Date Purchased:
Cost New: $
Value Now: $
Date of Last Survey (if applicable):
Owner’s Experience with Boats / ATV’s (5 years, 10 years, etc.):
Type of Owner’s Experience (Pleasure, Power Squadron, USCGA, Other Education):
Waters Navigated (Watercraft); (Inland, Atlantic, Pacific, Great Lakes, etc.):
Terrain Navigated (ATV); (Hills, Forest, Dunes, Rock, etc.):
Storage (Summer) Location:
Storage (Winter) Location:
Dry
Dry
Wet
Wet
OTHER QUESTIONS (If Applicable) (Check Box Below (“x”) for Yes):
Is The Boat Chartered To Others?:
How Often?:
Where To?:
Is The Boat Used Commercially or For Business Purposes?:
Is The Boat Used for Racing?:
How often?:
Duration of Race:
Is The Boat Used for Waterskiing?:
How Often?:
Does The Applicant Employ a Paid Crew?:
How Many Full-Time:
Any Sleeping Facilities?:
(Provide Number Of Beds):
Any Existing Damage to The Boat?:
Is The Boat Used as a Primary Residence?:
Any Additional Owners Not Listed as The Named Insured?:
Duration:
Purpose:
How Many Part-Time:
EQUIPMENT (If Applicable) (Check Box Below (“x”) for Yes):
Bilge Pump:
Cooking Stove:
Fume Detector:
CO2 / Chemical Systems:
Fire Extinguishers:
How Many:
Depth Sounder:
Fish Finder:
Radar:
Radio Direction Finder:
Ship-to-Shore Radio:
Anti-Theft Devices:
What Type:
Heater:
Air Conditioning:
Refrigerator:
TENDER / LIFE BOAT (If Applicable):
VIN/Serial#:
Year:
Make:
Model:
Length:
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Orange Insurance LLC
206.774.7867 [ Office ]
877.288.6103 [ Toll Free ]
206.774.2076 [ Fax ]
ron@insuredbyorange.com [ Email ]
www.insuredbyorange.com [ Web ]
TRAILER (If Applicable):
VIN/Serial#:
Year:
Make:
Model:
Length:
Axles (1, 2, etc.):
Wheels (2, 4, etc.):
Date Purchased:
Cost New: $
Value Now: $
{ Property, Owner & Policy Information }
Ownership Status:
Own
Vehicle Loan
Lease / Loan
If Lease or Loan, Provide Lien Holder Information:
•
Lien Holder Name:
•
Lien Holder Address:
•
Lien/Loan #:
Resident Type:
Own
Rent
Occupation:
Education:
High School
GED
Associates
Bachelors
Trade/Vocational
Other:
Did You Have Boater’s Education Classes (Y/N):
Driver's License #:
Owner’s D/O/Birth:
Owner's Age:
Owner's Gender:
Owner's Marital Status:
Yes
Masters
No
Owner's SSN:
 Providing your SSN will get access to more carriers and a more accurate quote.
 Call 206.774.7867 to leave on voicemail if you do not want to write it down.
Owner's Self-Credit Rating:
Excellent
Good
Fair
Poor
{ Current Insurance Information }
Copy of Your Current Policy (if Available): Provide is Possible.
Does This Replace an Existing Policy? (Y/N):
Yes
No
Expiration Date of Existing Policy:
Current Annual Premium: $
Current Insurance Carrier:
Length of Time Insured with This Carrier:
Number of Years Continuously Insured Overall:
Any Recent Claims (Y/N)?:
Yes
No
If Any Claims, Number of Claims in Past 3 Years:
Continued on the next page…
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Orange Insurance LLC
206.774.7867 [ Office ]
877.288.6103 [ Toll Free ]
206.774.2076 [ Fax ]
ron@insuredbyorange.com [ Email ]
www.insuredbyorange.com [ Web ]
{ New Insurance Information }
PHYSICAL DAMAGE:
Hull, Permanent Equipment & Tender: $
Unattached Equipment: $
Trailer: $
Personal Effects: $
Emergency Assistance / Towing: $
Hurricane Haul-Out:
Yes
No
If Hurricane Haul-Out, How Much Coverage: $
LIABILITY:
Desired Bodily Injury Coverage (each person/each accident):
$
50/100
100/300
250/500
Desired Property Damage Coverage (each accident):
$
50
100
250
500
Desired Underinsured Bodily Injury Coverage (each person/each accident):
$
50/100
100/300
250/500
Desired Underinsured Property Damage Coverage (each accident):
$
50
100
250
500
Desired Medical Payments Coverage (Including Water Skier):
$
1k
2k
3k
4k
5k
Desired Additional Special Coverage (If So, Please Specify):
Type of Additional Special Coverage:
Yes
No
Desired Effective Date of New Policy:
Desired Deductible Amount:
$
250
500
1,000
Multi-Policy Discount; for example - Home and Auto with the Same Carrier (Y/N):

Yes
No
RESIDENTS, DEPENDANTS (Licensed or Not) and REGULAR OPERATORS:
#1:
Name:
Gender:
Marital Status:
D/O/Birth:
Occupation:
Driver’s License Number:
Driver’s License State of Issue:
SSN:
Continued on the next page…
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Orange Insurance LLC
206.774.7867 [ Office ]
877.288.6103 [ Toll Free ]
206.774.2076 [ Fax ]
ron@insuredbyorange.com [ Email ]
www.insuredbyorange.com [ Web ]
#2:
Name:
Gender:
Marital Status:
D/O/Birth:
Occupation:
Driver’s License Number:
Driver’s License State of Issue:
SSN:
{ Additional Coverage Interests }
Health Insurance:
Yes
No
{ Additional Comments/Notes (If Applicable) }
 Once we get all of this information, we can get you a price indication within 12-24 hours and a firm,
bindable, quote within 24-48 hours.
 As a reminder, let me know if you need any other insurance needs. We handle it all; Property &
Casualty, Life & Health, LTC, Surety Bonds, Aviation and more! Everything for your personal life and business
ventures... (and you will often get discount for multiple policies with the same carrier)
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