Petruzelo Insurance Agency, Inc. - Get A Quote - Boats, Personal Watercraft & Yachts Quote

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	Boats, Personal Watercraft & Yachts Quote

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Personal Information Name*:
Current Address*:
City*:
State:
Zip*:
Home Phone*: - -
Work Phone: - -
E-mail*:
Date of Birth*:
How Did You Hear About Our Agency?:

Who*:

Other*:

Boating Experience Years Boating:
Boating Courses: USG
USPS
ASA
Capt. Lic.
List Previous Boats Owned:Size:
Make:
Size:
Make:
Size:
Make:
Prior Losses?:
If yes: Date:
Type:
Amount Paid:
List Any Driving Record Infractions over past 5 years: (Tickets, accidents, DUI's):

Vessel Year:
Length:
Make:
Model:
Max Speed:
Hull Material: Fiberglass
Wood
Steel
Aluminum
Other
Engines Make:
Number:
HP (each):
Fuel:
Drive Make:
Type: IB
OB
I/O
Equipment: VHF
Depth Finder
Radar
Loran
GPS
Sniffer
Dingy/Tender?:
Value:
Make/Type:
Trailer?:
Value:
Make/Type:
Vessel Surveyed?:
If Yes, Date Surveyed?:
Survey Type:Survey in Water
Survey Out of Water
Both IN and OUT of Water
Vessel Purchase Price:
Date Vessel Purchased:
Any Paid Crew?:
If yes, how many?:

Vessel Usage: Use: Pleasure
Charter (Six Pack)
Dockage: Mooring
Marina
Marina Name:
City:
State:
Off Season Lay-up?:
If yes, Lay-up Dates (from Month's): to

Navigation Atlantic
Gulf
Great Lakes
Chesapeake
Bahamas
Pacific
Caribbean
Inland Waters of (State):
Other:

Coverage's Requested	Coverage	Limit Deduction
Hull and Equipment		1% 2%
Outboard Motor
Liability
Trailer / Dingy
Medical Payments
Uninsured Boater
Personal Effects
Towing Coverage

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The submission of this form does not obligate you to purchase. This is for quoting purposes only and in no way provides, effects, or binds any insurance coverage.

We are licensed in the following states/provinces:
Connecticut, Maine, Massachusetts, New Hampshire, New York, Pennsylvania, Rhode Island, and Vermont

© 2009 Petruzelo Insurance Agency.   All rights reserved.
4 Research Parkway  | PO Box 5050  |  Wallingford, CT 06492-7550
Call Us Toll Free: 1-866-479-3327 | Fax: 203-269-7588
insure@petruzelo.com

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