Marine Insurance Quote Request - United Insurance Group

Owner(s) Full Name(s) *

Date of Birth(s) *

Full Address *

Phone *

Email *

Number of Years Experience *

Boating Qualifications *

Vessel Make & Model *

Vessel Name *

Length *

Year Built *

Vessel Material *

Country of Registration *

State of Registration (if applicable)

Make of Engine *

Year of Engine *

HP of Engine *

Max design speed (knots) *

Fuel Type

Petrol
Diesel

Name(s) of cruising associations or clubs you are a member of (if applicable)

Rigging age (if applicable)

Year of last survey (if possible please send a copy when returning this form to us)

Use (choose one)

Is your vessel used for racing?

Yes
No

If yes, please specify the type of racing and value of mast, spars, sails and rigging (if applicable)

Currency to quote in *

Purchase price (if applicable)

Purchase date (if applicable)

Tender Value $

Outboard Value $

Personal Effects Value $

Other Value (please list items and their value to be covered)

Vessel, machinery, gear and equipment current sum insured *

Mooring location *

Type of mooring *

Lay-up location (if applicable)

Lay-up dates (if applicable)

Cruising area for the 12 month insurable period *

No claims bonus entitlement

Yes
No

Have you had any claims in the past 5 years?

Yes
No

If yes, please specify the year of claim, details of the claim and amount paid out by the insurer

Finance Interest. Please specify the Finance Company name, address and agreement number (if applicable)

Current insurer (if applicable)

Renewal Date (if applicable)

How did you hear about us?

Any other information (if applicable)

STATEMENT: Facts Omitted or Misrepresented The Policy or any subsequent renewal may be deemed invalid if the insured or anyone acting on the insured’s behalf has obtained cover through omission or inaccuracy of any response provided in this Form. In the event that Insurers void the Policy a refund of premium may not be made. *

I have read and agree to the statement above

DECLARATION: I/We have had no other insurer at any time refused to insure you, imposed special terms or requested extra precautions. I/We/or any persons having an interest in the boat have never been convicted of arson, or of any offence involving dishonesty of any kind such as smuggling, fraud, robbery, theft or handling stolen goods. I/We declare that the statements and particulars contained in this form are true and complete. I/We will provide details of any alteration to this information as soon as possible prior to commencement of the period of insurance. I/We agree that if any answers have been completed by any other person, such person shall for that purposes be regarded as my/our agent and acting on my/our behalf, and not the agent of Topsail Insurance. I/We agree to receive the insurance quote and all other correspondence by email, to the email address provided (copy) *

I have read and agree to the declaration above