StevensMarineLogo_FINALV3Request a Quote

Date of Birth

Home Phone Number

Home Address

City

Zip Code

State

Social Security #

Motor Vehicle Accident in the past 3 years
YesNo

If yes, please describe below

Years of experience as owner

Years of experience as crew

Types of boats owned and operated

Formal Coarses
USCGUS Power SquadronUSCG License CaptainOther

Have you had an watercraft losses or claims in the past 5 years?
YesNo

If yes, please describe below

Year of Boat

Manufacturer

Model

Length (in feet)

Construction

If other, please explain

Type

Engine Type

Number of Engines

Total Horsepower

Fuel
DieselGasolineNone

Top Speed

Fume Detector
YesNo

Automatic Fire Detector
YesNo

Navigational Equipment
CompassDepth SounderGPSRadarVHF Radio

Date of Survey, if available

Water-Skiing
YesNo

Year of Trailer

Manufacturer of Trailer

Value

Year of Tender

Engine Manufacturer

Use
Private PleasureCharter

If Charter, please describe

Date Normally Launched

Date Normally Hauled

Where stored in the summer?

Where stored in the winter?

Navigation Limits
Atlantic CoastGreat LakesGulf of MexicoInland LakesOther

If other, please explain

Amount of Insurance on Hull & Machinery ($)

Deductible

If other, please list deductible

Fishing Equipment Value ($)

Amount of Insurance on Trailer ($)

Watercraft Liability

Medical Payment

If other, please list medical payment

Current Insurance Company Expiration Date Current Premium

Vanner Insurance Agency
11 Pinchot Court, Suite 100
Amherst, New York 14228

Phone: 716.688.8888

Email: info@vannerinsurance.com