IMIS Quote Request

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IMIS Quote Request

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Please complete and submit the form below. However, if you would rather complete the form offline, you may download a quote request form which can be completed offline and then mailed or faxed to us.

Personal Information

The personal information you provide will not be used by IMIS or the insurers it represents except for the purpose of determining the present availability and cost of the insurance you specify below. Your contact information will not be used by us or others to contact you again at a later time unless you choose to have IMIS arrange such insurance for you.

Name of applicant

Address

Telephone

Fax E-mail

Occupation

(if retired please also indicate prior occupation)

Citizenship

Date of birth

Years boating Years as boatowner

Largest prior vessel

(describe vessel and when owned and where operated)

Second largest vessel

(describe vessel and when owned and where operated)

Boating courses taken

(please also list any boating licenses held)

Place a check next to each of the following statements that are true:

	I have not been cited for any boating or motor vehicle violations in the past five years.
	I have not made any insurance claims against any boat or motor vehicle insurance policy in the past five years.
	I have never been denied an insurance policy by an insurance company for boat or motor vehicle insurance.
	I have never had a boating or motor vehicle license suspended or revoked.
	I have never been convicted of a felony.
	No one will operate the vessel on a regular basis without me aboard.
	No captain or crew will be hired to operate or assist in the operation of the vessel.

If any statement was not checked please provide details of the relevant circumstances in the Comments section below.

Vessel Information

Owners

(if other than applicant named above)

Name

Builder

Model

Style

Year

Length Construction

Place Built

Place Registered

Propulsion

Type: Gasoline Diesel Year: (if other than vessel year)
Single Twin Triple HP each: Maximum MPH:

Equipment

Automatic fire extinguisher Fume detector Theft alarm High water alarm RADAR VHF radio Depthsounder LoRan GPS
Dinghy with motor Dinghy w/o motor Liferaft Trailer

Particularly if the vessel will be traveling internationally, please describe any additional safety, navigation or other equipment aboard or other preparations you have made to enhance the seaworthiness of the vessel and the safety of its crew.

Spars

(if the vessel is a sailboat please specify the material of the spars)

Damage

(please describe any existing damage or other faults of the vessel)

Survey

(indicate date of latest professional survey and whether or not the vessel was ashore for this)

Usage Information

Type of use	Recreational Liveaboard Racing Trailering Waterskiing Bareboat charter Crewed charter Commercial use other than charter
Time of use	Year-round use Kept in port From: Until: Stored ashore From: Until:
Area of use	Coastal waters Between: And: Nontidal waters of U.S. Bahamas Cuba Caribbean Mexico Canada Great Lakes Chesapeake Bay San Francisco Bay Puget Sound Other:
Mooring	Fulltime cruising Year-round At: Seasonal Winter at: Summer at:

Coverage Information

Present insurer of vessel	Expiration date of policy
Purchase cost of vessel	Date of purchase
Estimated current value	(if other than purchase cost)
Desired insurance amount	(if other than current value)
Deductible	1% 2% 3% 4% 5% 10% (percentage of insurance amount)
Value of dinghy & motor	(include in current value)
Value of trailer	(include in current value)
Liability insurance	$300,000 $500,000 $1,000,000 Other:

Comments

Please use the space below to expound upon any of the information provided above or to advise us of any peculiar circumstances of which we should know. If any use other than recreational was indicated above, please provide below details of the planned use. Please also use the space below to specify any supplemental coverages in which you are interested.

Please let us know how you came to learn about IMIS:

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Last edited May 30, 2008
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