Home Advocate Insurance Group

6250 Old Dobbin Ln, Suite 100, Columbia, MD 21045
Phone: (443) 430-2390 | Toll Free: (877) 487-8341
Fax: (866) 922-3014 | info@homeadvocate.net

Please provide as much information possible in the form below. This information will be kept confidential and will be used only for quote purposes.

Operator's General Information

Name:

Address:

City:

State:

Zip code:

County:

Email:

Office phone:

Home phone:

Best time to call:

am pm

Occupation:

Soc. Sec. #:

Driver's License Number:

State Issued: Year Issued:

Date of birth:

USCG/Power Squadron Certificate:

Current Boat/Watercraft Insurance Information

Company name:

Policy expiration date:

/ /

Premium:

Term:

6 Months 1 Year Other

Vessel Information

Vessel Name:

Length: Registration #

Manufacturer/Model:

Year: Maximum speed: mph

Date Purchased:

Purchased price: Present value:

Hull Identification #:

Tenders or Dinghies:

Waters to be navigated:

Storage Address

Address:

City:

State:

Zip code:

County:

Stored on trailer ?:

yes no

Will it be trailered over 100 miles?:

yes no

Laid up

Duration:

From: Until:

Location:

On Shore Afloat

Miscellaneous

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

On-board Equipment

Please select ALL equipment on your Boat/Watercraft
Bilge Pumps	CO2/Halon System	Aux Generator, Diesel
EPIRB	Fume Detector	Aux Generator, Gas
Sonar	Fire Extinguishers	Others (please list below):
Depth Sounder	Cooking Stove
LORAN/ Direction Finder	Engine Alarm
GPS	Anti-theft Devices
Radar	Life Raft
SATNAV/ OMEGA	Ship to Shore Radio

Engine/Outboard Motor Information

Eng	H.P.	Gas	Diesel	Year	Date Purchased:	Purchase Price:	Present Value
1						$	$
2						$	$
3						$	$
	Manufacturer/Model					Serial Number
1
2
3

Trailer Information

Year:

Manufacturer/Model:

Date Purchased:

Purchased price: Present value:

Serial #:

Desired Coverages

Coverage type :	Sum Insured :	Coverage Type :	Sum Insured:
Hull- Physical Damage	$	Tender / Dinghy	$
Liability Coverage	$	Crew Liability	$
Owner / Operator M&C	$	Medical Payments	$
Commercial Passenger Liability	$	Uninsured Boater	$
Trailer	$	Personal Property	$
Non-Emergency Towing	$	Other	$

Boat/Watercraft Usage Information

Is the boat chartered to others with captain?:

yes no

Is the boat chartered to others without captain?:

yes no

Is the boat used for racing?:

yes no

Is the boat used for water skiing or diving?:

yes no

Is the boat used commercially or for business purposes?:

yes no

Does the applicant employ a paid crew?:

yes no

Was any operator involved in a marine loss in the last 10 years (insured or not)?:

yes no

Was any coverage declined, cancelled or non-renewed during the last 5 years?:

yes no

Please explain any of the answer marked 'yes' above:

If the boat is used for fare paying passenger charters, please specify below:

Average number of passengers per trip:

Number of trips per year:

Previous violations

Please list all involved in violations and suspensions within the past 5 years:
Description:	Years of ownership when occured:

Additional Information

Please give any some comments about the coverage you desire:

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Home Advocate, LLC is a proud member of the Independent Insurance Agents & Brokers of America			Privacy Policies \| info@homeadvocate.net Phone: (443) 430-2390 \| Toll Free: (877) 487-8341 \| Fax: (866) 922-3014