Online Quote Request Form – Island Wide Marine Agency

Quote Request Form – Online Version

- Step 1 of 4

Personal Information

Name *

First

Last

Date of Birth *

Drivers License Number (optional)

Occupation *

Phone Number *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Boat Information

Boat Type *

Sailboat
Cruiser
Center Console
Trawler
Wake / Ski
Other

If Other, Write Type

Boats Year, Make and Model (Please include all details) *

# of Motors *

Total HP *

Engine Year Make and Model *

Purchase Date *

Purchase Price: $ *

Hull Type *

If Other, Type Hull Type

Engine Type *

If Other, Write Engine Type

Fuel Type *

If Other, Write Fuel Type

Top Speed (MPH) *

Trailer Coverage? *

Navigation Requirements (Where do you use the boat?) *

Where is the vessel located when not in use (ie: residence, name of marina, private dock) *

Main Mooring Location (City & State) *

Main Mooring Zip Code *

Automatic Fire Extinguishing System in the engine compartment: *

Gas Fume Detector in the engine compartment: *

GPS Anti Theft *

Is the vessel used as the primary residence: *

Does Insured Live More Than 4 Hours From The Vessel? *

Use of Vessel *

If Other, Write Vessel Use

# of months in lay up

Lay up start date (month and day)

Years of Boating Experience *

Boater Safety Class *

Year Make Model of boats you have owned (Up to 3- Very important for eligibility) *

Coverages Requested

Vessel Value *

Trailer Value: (if needed)

Liability Limit: *

If Other, Write Liability Limit

Medical Payments: *

If Other, Write Medical Payments

Personal Effects: Limit is based on the type of boat or you can select the limit desired

Current Insurance Information

(Not required for new purchase)

Insurance Company: (Put N/A if No Insurance) *

Premium:

Expiration Date:

Any Reported Boat Losses in Last 5 Years: *

If yes please explain (date, amount paid, brief description)

Has any insurance coverage ever been Cancelled or Refused: *

Note to Agent:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Fillable Online Forms

Quote Request Form – Online Version

Personal Information

Boat Information

Coverages Requested

Current Insurance Information

Email Us:

Our Phone:

Our Fax:

Mailing Address

Our Hours: