Keenan Marine Insurance

A better approach to marine insurance.

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Owner Information
	Salutation
	Name*

	Address*
	City*	State*	Zip Code*

	Phone*	Best Time to Call	Home	Work
	Work Phone	Fax
	Email Address*

	Type of Ownership*	If partnership, number of partners
	Current Insurer	Expiration Date	Premium



Vessel Information
	Type	If "Other" is selected, please describe

	Construction:	Fiberglass	Aluminum
	Other construction - please describe

	Make/Builder*	Model	Year	Length
	Last Survey	Survey Type
	Maximum Speed	Purchase Year	Purchase Price



Safety Equipment
	Automatic Fire Suppression System		Radar	Carbon Monoxide Detector
	Gas Fume Detector	Anti-Theft	Other



Use of Vessel
	Principal Mooring/Storage Address
	Street	City	State	Zip Code
	County

	Seasonal Use?	Yes	No

	Lay Up Location:	City	State
	Lay Up Dates (Month/Day)	through (Month/Day)

	Lay Up Mode	Hauled Afloat	Afloat with bubbler

	Navigation Area
	Other Navigation Area

	Vessel Use
	Personal/Pleasure	Primary Residence	Chartered	How Many/Year?
	Commercial Use (Explain in Comments)		Paid Crew/Captain	How Many?
	Scuba Diving	Raced



Desired Coverage (indicate dollar amount)
	Boat (Hull, Machinery and Equipment)	Deductible 1%2%3%	Other % or $ Amount

	Liability (P & I)
	$100,000	$300,000	$500,000
	$1 Million	Other Liability Amount

	Personal Property	Medical Payments	Fishing Gear
	Trailer	Dinghy & Dinghy Engine	Towing

	Describe any other coverage desired		Amount
	Note: We automatically include coverage for Uninsured Boater and Fuel Spill Liability.



Principal Operator
	Name			Date Of Birth
	Homeowner	MarriedSingle	Occupation

	Boating Courses
	USPS	USCGA	Other	If licensed captain, indicate rating
	Boat Ownership Yrs.		Boating Experience Yrs.



Boat Insurance History
	Number of claims in last 5 years?
	Please provide date, dollar amount and detail below.
	In the past five years, have you had boat insurance cancelled or renewal refused,
	other than for nonpayment of premium, or because the insurer withdrew from the market?
		YesNo
	Please provide detail below.



Motor Vehicle Driving Record - past 3 years
	In the past 36 months, how many violations/at-fault accidents have you had?
	For each incident, please provide the approximate date (mm/yy) and indicate either at-fault accident or the type of violation:



Additional Operator(s)

	Name	Married	Single
	Relationship	Date of Birth	Yrs. Exp.
	In the past 36 months, how many violations/at-fault accidents has operator had?
	For each incident, please provide the approximate date (mm/yy) and indicate either at-fault accident or the type of violation:

	Name	Married	Single
	Relationship	Date of Birth	Yrs. Exp.
	In the past 36 months, how many violations/at-fault accidents has operator had?
	For each incident, please provide the approximate date (mm/yy) and indicate either at-fault accident or the type of violation:



Comments
	Important notice! Certain of our insurers require a consumer report check in connection with rating. If you wish that we not quote with such companies, please so indicate in Comments below.

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