Hayden Yacht Insurance
LICENSE #0635700
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
 
 
   
 
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