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Yacht Quotation Request Form

* Required

Application Contact Information

Prefix:

* First Name:

* Surname:

* Address 1:

Address 2:

* City:

* State / Province:

* Zip / Postal Code:

* Country:

* Citizenship:

* Country of Residence:

* Telephone:

Fax Number:

* E-mail:

* Occupation:

* Date of Birth:

* Experience in Vessel Operations:

* Describe your area of Navigation:

 

Vessel Information

* Purchase Price :

$

* Purchase Date:

* Vessel Name:

* Flag:

* Registration Number:

* Vessel Make:

* Vessel Type:

* Vessel Model:

* Vessel Construction:

* Vessel Length:

* Vessel Age or Year Build:

* Engine Type (in/outboard):

* Engine Make:

* Engine Horsepower:

* Maximum Speed:

* Engine, Year Built:

* Months in Commission (not Moored):

* Place of Mooring:

country
city
dock

* Cruising Range:

* Use of Vessel:

* Does anybody live aboard?

Yes No

Check all that apply:

VHF Radio
GPS
Radar
Bilge Alarm
Fume Alarm
Depth Finder
Auto Pilot
Anti-Theft Devices
Auto Fire Extinguishers
Other
Explain:

* List Active Risks:

 

Survey Information

* Last Survey Date:

* In or Out of Water?

In Out

* Surveyor's Name:

* Surveyor's Address:

* Date of Last Haul Out:

* Major Maintenance :

* Market Value:

$

* Replacement Value:

$

 

Requested & Current Insurance

* Hull, Machinery and Equipment:

$

* Liability Coverage:

$

* Outboard Engine:

$

* Tender / Life raft :

$

* Personal Effects:

$

* Trailer:

$

* Current Insurer:

* Policy Expires:

* Policy Premium:

$

* Has your coverage ever been revoked, cancelled or not renewed by the insurance carrier?

Yes No
If yes, please explain:

* Boating losses in last 5 years?

 

Crew Information

Total Crew:

Full Time:

Part Time:

Liability:

$

Medical Insurance:

$

Life Insurance:

$

Disability Insurance:

$

 

Countries Visited

 

Questions

* Does anyone else have a financial interest in the vessel(s)?

Yes No
If yes, then explain:

* Do you charter out this vessel ?

Yes No
If yes, then explain the type of activity and frequency:

* Is the vessel(s) pledged property?

Yes No

* Do you have a valid drivers license?

Yes No

* What state/province & country?

If no, then explain:

   
 
   

PHONE: +1-866-510-0149

International Insurance & Investments LLC

1725 Washington Rd. · Suite 406
Pittsburgh, PA. 15241 USA

International Insurance & Investments LLC is licensed in the European Economic Area, Switzerland, The United Kingdom and the United States of America. In the USA, the firm is licensed in 17 states. In the United Kingdom, the firm is authorized and regulated by the Financial Services Authority # 315054.


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