Hopf & Hopf Insurance, Inc.

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

Information

Please be sure to complete all of the requested information so that your agent may contact you after receiving this notification.

Named Insured:

Address:

City:

State:

Zip:

Day Phone:

Eve. Phone:

Beeper:

Cell Phone:

E-mail Address:

Best Time To Contact:

AM PM

Method of contact:

Current Policy Information

Agent:

Insurance Company:

Policy Number:

Policy Expiration Date:

Coverage's
(input desired coverages)

Type	Amounts
Hull	$
Liability Coverage	$
Owner / Operator M&C	$
Commercial Passenger Liability	$
Trailer	$
Uninsured Boater	$
Personal Property	$
Medical Payments	$
Non-Emergency Towing	$

Vessel Information

Vessel Name (if any):

Manufacturer/Model:

Hull Identification #:

Year:

Length:

Date Purchased:

Purchase Price:

Present Value:

Max Speed:

mph

Registration #

Engine 1
H.P.
Gas/Diesel:	GasDiesel
Inboard/Outboard I/O:	InboardOutboard I/O
Manufacturer:
Serial:
Engine 2
H.P.
Gas/Diesel:	GasDiesel
Inboard/Outboard I/O:	InboardOutboard I/O
Manufacturer:
Serial:
Engine 3
H.P.
Gas/Diesel:	GasDiesel
Inboard/Outboard I/O:	InboardOutboard I/O
Manufacturer:
Serial:

Location of Vessel:

Tenders or Dinghies:

Waters navigated:

Boat/ Watercraft Equipment
(please list ALL equipment on your Boat/Watercraft. Use the other to list equipment not indicated)

Bilge Pumps	CO2/Halon System	Aux Generator, Diesel
EPIRB	Fume Detector	Aux Generator, Gas
Sonar/radar	Fire Extinguishers	Other (list below)
Depth Sounder	Cooking Stove
LORAN	Engine Alarm
GPS	Anti-theft Devices
Stereo System	Life Raft
SATNAV	Ship to Shore Radio

Miscellaneous
(please check ALL that apply)

Primary Power	Type of Hull	Hull Material	Fuel Tank
Sail	Sailboat	Wood	Metal
Outboard	Performance	Metal	Fiberglass
Inboard	Runabout	Fiberglass
Inboard/ Outdrive
Other

Trailer Information

Year:

Date Purchased:

Purchase Price:

Present Value:

Manufacturer/Model:

Serial #:

Operators

#	Name	DOB	Auto DL #	State	Social Security #	USCG/Power Squadron Certificate
1
2					n/a
3					n/a
#	Auto Violations/Suspensions in last 5 years:					Years of Boat Ownership:
1
2
3

Boat/Watercraft Usage
Explain all YES responses in EXPLANATIONS Section below.
1	Is the boat a charter boat?	Y N	6	If boat is used commercially, is there crew? If so how many? (below)	Y N
2	Is the boat used commercially ?	Y N	7	Was any operator involved in a marine loss in the last 10 years (insured or not)?	Y N
3	Is the boat used for racing?	Y N	8	Was any coverage declined, cancelled or non-renewed during the last 5 years?	Y N
4	Will you be water skiing or diving with your boat?	Y N
5	If the boat is used for charters, what is the average number of passengers and trips. per trip? Number of trips per year?
EXPLANATIONS

Additional Information Section

In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverages engines, etc.