A SERVICE FROM
Gig Harbor Yacht Sales
MARINE INSURANCE REFERRAL FORM



If you want a FREE estimate for yacht insurance, just fill out this form and submit it. We will get a quote back to you as soon as possible.

 

INSURED INFORMATION
Name Of Insured:
Address Of Insured:
Address 2:
City:
State:
Zip:
Phone:
Fax:
E-Mail:

BOAT DESCRIPTION
Power Or Sail:
Manufacturer:
Model:
Hull Material:
Length:
Year Built:
Replacement Value:
Market Value:
Purchase Price:
Purchase Date:
ENGINE
Type Of Engine:
Manufacturer:
Number Of Engines:
HP:
Gas Or Diesel:
EQUIPMENT
Please Select The Type Of Equipment (Choose All That Apply):
CO2
HALON
VHF
RADAR
AUTO PILOT
DEPTHFINDER
 
LORAN
GPS
SINGLE SIDE BAND
EPIRB
LIFE RAFT
DINGHY
Dinghy Description:
Other Safety & Navigation Equipment:
LOCATION AND USE
Normally Navigated Waters:
Mooring Location:
Additional Insured:
Who:
Intended Use:
PERSONAL
BUSINESS
CHARTER
Other:
Paid Crew:
How Many:
Names Of Paid Crew Members:
MARINE SURVEY INFORMATION
Last Marine Survey Date:
By Whom:
Survey Location:
Are All Survey Recommendations Complied With?:
Which Items Still Require Compliance?:
SPECIAL TRIP INSURANCE
From What Location:
To What Location:
Departure Date:
Returning Date:
Number Of Crew Members:

OPERATOR INFORMATION
Occupation:
Date of Birth:
Years Boating Experience:
Years Of Ownership:
Will You Live Aboard?:
Largest 2 Previous Boars Owned Or Operated:
Length & Manufacturer:
 		  Owned/Operated?:
     
Length & Manufacturer:
 		  Owned/Operated?:
     
Boating/Navigation Courses Completed & Licenses Obtained:
Losses Within The Past 5 Years:
Previous Insurer:
Expiration Date Of Last Policy:
Has Your Insurance Ever Been Canceled Or Non-Renewed?:
If So, Please Explain:

 

GIG HARBOR YACHT SALES GIG HARBOR YACHT SALES
GIG HARBOR OFFICE POULSBO OFFICE
3119 HARBORVIEW DRIVE 18779 FRONT STREET, SUITE D
GIG HARBOR, WA 98335 P.O. BOX 335
TEL: 253-851-2674 POULSBO, WA 98370
FAX: 253-858-2674 TEL: 360-697-8488
FAX: 360-779-1850
E-Mail Logo
E-Mail: Gig Harbor Yacht Sales		 E-Mail Logo
E-Mail: Gig Harbor Yacht Sales - Poulsbo