please send quote to Susan

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==INTERNATIONAL MARINE INSURANCE SERVICES==
===VESSEL INSURANCE QUOTE REQUEST FORM====

OWNERSHIP:
 Owner(s)-
 Street address-
 City / State / ZIP-
 Home phone-                                 
 Work phone-
 E-Mail address-
 Lienholder? -

OPERATOR(S):
 Name-
 Date of Birth-         
 Occupation-
 Years of boating experience-                
 Size(s) & Type(s) of Boat(s) operated-
 Years of boat ownership (any boat)-         
 Size(s) & Type(s) of Boat(s) owned (& for how long)-
 Boating courses completed-
 License held (if any)-
 Current insurance company-                  
 Expiration date-
 Describe boating accidents or losses, last 5 years-
	(date, cause, amount)

 (repeat details for any other regular operator)-


BOAT:
 Model year-      
 Builder-              
 Model (or rig)-          
 Length overall-   
 Construction-                              
 Flag-
 Purchase Date-                             
 Purchase Cost-
 Total Investment-
	(improvements, not maintenance)

ENGINE(S):
 Number-         
 Year(s)-             
 Manufacturer(s)-                       
 Total Horsepower-     
 Fuel-

EQUIPMENT:
 Automatic extinguisher [ ]    
 Fume detector [ ]     
 Theft Alarm [ ]
 VHF radio [ ]    
 Depth finder [ ]    
 Loran or GPS [ ]    
 Radar [ ] 
 EPIRB [ ]
 Sextant [ ]
 Paper Charts [ ]	
 Weather Fax [ ]
 Storm Sails [ ]
 Describe Ground Tackle-
 Other safety gear-

TENDER:
 Model year-       
 Builder-                          
 Model or length-
 Engine year-      
 Manufacturer-                     
 Horsepower-

USE:
 Private pleasure [ ]    
 Liveaboard [ ]
 Captain charter [ ]    
 Bareboat charter [ ]	  
 Racing [ ]
 Number of paid crew [ ]
 Navigation area-

 Regular Mooring Location-
 Lay-up Period-
 Afloat or Ashore?

COVERAGE:
 Hull & equipment value-		           
 Deductible-
 Liability limit-
 Tender value & motor value-
 Other specifications-

How did you learn about International Marine Insurance Services?-

COMMENTS: