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Please fill out this form completing each field (especially where REQUIRED *) and we will get in touch with you shortly.
Email
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Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Phone
*
Occupation
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If retired, previous occupation
*
Marital Status
*
Married
Single
Divorced
Domestic Partner
Widowed
Date of Birth
*
Primary Residence
*
Select value
Own
Rent
Other
Any driving violations in past 5 years?
*
Yes
No
If yes, please explain:
Date Boat Purchased
*
Purchase Price + Sales Tax
*
Boat Year
*
Boat Length
*
Hull Manufacturer
*
Hull Model (Please be specific -- example: 175BR, 400EC, 3888, 3807 Aft, Sloop, etc)
*
Boat Storage Location/Marina Name
*
Is this vessel insured today?
*
Select value
Yes
No
Current Insurance Company
*
Make of Engine 1
*
Engine 1 - Fuel Type
*
Engine 1 - Horsepower
*
Engine 1
*
Select value
Inboard
Outboard
Inboard/Outboard
Make of Engine 2
Engine 2 - Fuel Type
Engine 2 - Horsepower
Engine 2
Select value
Inboard
Outboard
Inboard/Outboard
When was the last time the boat was out of the water for service? If never, type none.
*
Last marine survey (vessels in excess of 28 feet only). Type MONTH & YEAR (if none, type NONE)
*
Waters to be navigated (please be as specific as possible):
*
Please check all of the following that apply
*
VHF
GPS
SSB
Fume Detector
Depth Sounder
Chart Plotter
Auto Fire Extinguisher
EPIRB
Radar
Auto Pilot
Do you live aboard?
*
Yes
No
If you Live Aboard, select below:
Full Time
Part Time
Please list any other regular boat operators (If none, type none)
*
Do you own a trailer?
*
Select value
Yes
No
If you own a trailer, what type?
Select value
Single Axle
Tandem Axle
Tri Axle
Trailer Manufacturer?
Number of years boating experience
*
How many years have you owned boats?
*
Previous Boat(s) Owned: Model / Length and How Many Years (If none, enter 0):
*
Past boating claims? Please explain. If None, enter "none".
*
Ever been refused or cancelled marine insurance? If YES, please explain below.
*
Yes
No
Previous Insurance Cancellation Reason:
If not insured, when was the last time the vessel was insured?
Have you ever taken safe boating classes?
*
Yes
No
If YES, please list the classes:
Please provide any additional comments here
Please attached Survey, Photos, or any other pertintent documents.
Please attach any other documents.
How did you find Twin Rivers Marine Insurance?
*
Magazine
Radio Ad
Boat Sales Facility
Boat Yard or Marina
Yacht Club
Online Search
Other
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