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Elton Porter Insurance Agency - Quote Form

Elton Porter Boat Insurance Agency Recreational Insurance Experts
Insurance Agency
"Recreational Insurance Experts"

We are unable to quote boats over 25 years of age.
Complete the information below for FREE quote
--or-- click for quote by phone

Name:
Address:
City:   State/Province:
Zip/Postal:   County:
Phone:
Fax:
E-mail:
   
  Past 3 years driving record:
Occupation:   Duration: (yrs)
   
Boat:
Manufacturer:
Model:
Year:
Length :
Value:
Do you currently own this boat?
Yes No   How long?
Are you looking to purchase this boat?
Yes No   How soon?
Construction
Boat type
   
Engines:
Manufacturer:
Horse Power: (per engine)
Type of Engine(s)
Number of engine(s)
   
Trailer:
Manufacturer:
Year:
Value:
   
Dinghy:
Manufacturer:
Year:
Value:
   
Safety/Anti Theft
Equipment
Auto CO2/Halon
Depthsounder
Radar
VHF / Ship to shore radio
GPS
Burglar Alarm
Outboard or Outdrive Locks
Propeller Lock
Fume detection system
Other (please describe)
   
Navigation
Areas:
NE Atlantic Only
SE Altantic Only
Mid-Alantic
Atlantic Coastwise
Cheaspeake
Great Lakes
Lake Mead, Powell, Tahoe
Gulf
Pacific Coasts
Inland only
Bahamas
Other (please describe)
   
Location: (Vessel) While in Commission
Mooring / Storage address:

Marina   Residence   Other
   
Winter Lay Up:
Afloat Ashore

Mooring / Storage address:

Marina   Residence   Other
From:
To:
   
Vessel Use: Private Pleasure Charter
If charter use, how many per year:
Other Vessel use:
Please describe
Captain:  
Describe Captain
Marine Course:
Paid Crew: #
Part-time Crew: #
   
Owner's: Boating Experience and Loss Information:
Date of birth:
Married Single
Additional Operator(s):
Name D.O.B.
Name D.O.B.
Name D.O.B.
Years Experience:

Captains License(s) Type:
USPS USGG     License Type:

Types of boats owned:
(Be specific, yr/make//model/lenght/years owned)

Please describe any losses and amounts, during past 3 years:
   
Survey:
By Whom:
Date:
   
 
Hull and Equipment Deductible:
P&I-Watercraft liability:
Medical payments:
   
Current:
Insurance Company:
Expiration Date:
Premium:
   
  How did you find our site?
Which one:
   
Comments:

 

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