3432 Via Oporto Ste. 104
Newport Beach, CA 92663

Toll Free:
1-800-723-1170

Phone:
949-723-1170

Fax:
949-723-1171

Email:

For your complimentary pleasure vessel quote, please fill in the following form:


Name:
Address:
 
City:
State:
Zip:
Day Phone (w/ area code):
Eve. Phone (w/ area code):
Fax (w/ area code):
Email Address:
Occupation:
Date of Birth:
Experience in Vessel Operation: Years
Current Insurer:
Policy Expires:
Premium:
Boat name:
Manufacturer:
Model:
  Power     Sail
Year Built:
Length:
Hull Material:
Number of Engines:
Total HP:
Top Speed:
Engine Manufacturer:
Fuel:
Check all that apply: VHF Radio
GPS
Radar
Bilge Alarm
Auto Alarm
Fume Alarm
Depth Finder
Anti-Theft Devices
Auto Pilot
Other   
Last Survey Date:
  In Water    Out of Water
Surveyor's name:
Date of Last Haul Out:
Market value:
Replacement value:
Boating Courses Completed: USCG
USPS
ASA
College
Sailing Club
Private Instruction
Other
Previous Vessels Owned:
Vessel Location:
Describe your area of navigation:
Purchase Price of Watercraft:
Date of Purchase:
Live Aboard: Yes    No
Amount of Hull Insurance Desired:
Liability Coverage:
Other:
Hull Deductible:
Tender value:
Outboard value:
Personal Effects Amount:
Trailer value:
Boating Losses in Last 5 Years: Yes    No
(If yes, explain):
Boating Courses:
Driving Record:
How were you referred to
Hayden Yacht Insurance?;
If other, please specify:
QUESTIONS / COMMENTS