Marinalife Insurance ServicesMarinalife Boaters Insurance Application

Insurance Main
The following application is designed to provide us with sufficient information so that we can provide you with a personalized quotation that fully addresses your marine insurance needs. Please complete the information on the form below and return to us at Marinalife Insurance Services at your convenience. We will prepare and deliver a quote to you via email or fax within 48 hours. For immediate assistance, call us on (800) 736-8275 or (410) 752 0505.
Personal Information:* Denotes a required field
First Name *
 
Existing Marinalife members please log in.
Last Name *
 
Address 1 *
 
Address 2
City *
 
State *
 
Zip Code *
 
Telephone *
 
Please Include Area Code (xxx-xxx-xxxx)
Fax
 
Please Include Area Code (xxx-xxx-xxxx)
Email Address *
 
Your Date of Birth *
 
Occupation
How would you like your quote delivered?
Vessel Information
Vessel Name *
 
Type *
 
Builder *
 
Model *
 
Year Built *
 
Hull Material *
 
Mast Material (if applicable)
Purchase Date (year) *
 
Purchase Price *
 
Estimated Current Market Value *
 
Length Overall (ft) *
 
Beam *
 
ft
in
Draught *
 
ft
in
Max Speed *
 
 
Engine Manufacturer *
 
Number of Engines *
 
Engine HP (each) *
 
Year
 
Engine Type *
 
Fuel
 
Hull ID Number *
 
Registration *
 
Primary Summer Dockage Location *
 
(name, city, state)
Type of Summer Dockage *
 
Location (region)
Is the Vessels Winter Dockage Location Different?
 
Date Last Surveyed (if known)
 
Name of Surveyor (if applicable)
Market Value assigned by Surveyor (if known)
 
Tender (if applicable)
Tender Manufacturer and Model
Year
 
Length
 
Value
 
Tender Outboard Manufacturer
Year
 
HP
 
Value
 
Trailer Make
Year
 
Value
 
Mortgage/Financing Details
Do you have a mortgage or loan on the vessel? *
 
Operations
Type of Operation *
 
Total Annual Usage (Estimate) *
 
Navigation Area *
 
Current Policy
Present Insurer
Annual Premium
 
Policy Expiration Date
 
Requested Coverage
Hull and Machinery Sum Insured *
 
Personal Effects
 
Tender
 
Hull and Machinery Deductible *
 
Liability (P and I) Limit *
 
P and I Limits available from Marinalife Insurance Services are not guarantees of adequacy. Higher or lower limits may be available upon request.
Boating Experience and Loss History
Years of Boating Experience *
 
Years as Boat Owner *
 
Boating Courses Completed/Qualifications
Significant Affiliations/Memberships
Previous Vessels Owned
 
List all hull and/or liability losses you have experienced regarding any vessel in the past 5 years.
Date
 
Type of Loss
 
Amount
 
Brief Description
 
Please Provide details of any violations/suspensions in the last 5 years (including Auto) and advise if ever convicted of a criminal offense or pleaded no contest:
 
Other Information
How did you hear about us?
Additional Comments
 
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