Affiliated Insurance Agencies, Inc., Hazelwood, Missouri

	Please take the time to fill out the following information so we can provide you with a free, no obligation insurance quote. Please provide as much information, as possible, for the most accurate quote. This information is confidential and will be used for quote purposes ONLY. You will receive a quote by e-mail, fax or phone within 24 hours of submission of online questionnaire. You are always welcome to call an agent.
*REQUIRED
Basic Information *Required information

First name*
MI
Last name*
Address *
City*
State*
Zip*
Marital Status
Best way to be contacted?*
Phone number (add area code)*
Best time to call*
Fax number
Work number
E-mail address *
Occupation
How long
Additional Comments:

Vessel Information

Vessel Name
Year Built/Rebuilt
Length
Beam
Draft
Hull Construction

Engines

Number
Manufacturer
Horsepower
Fuel
Vessel to be used for
Berthed
Waters to be navigated

Hull Information

Market Value
Last surveyed
Are you currently insured?
If insured, insurance carrier:
Premium

Protection and Indemnity

Limit of Liability Required
Number of Crew
Number of Passengers (maximum)
Date you want policy to go into effect	/ /

Watercraft Information

Use
Year
Make
Model
Length
Max speed
Horsepower
Fuel
Moored / Location
Laid Up / Location
Lay-up Dates	From To
Navigation Limits

Trailer

Year
Manufacturer

Owner Record

Years Boating Experience
Losses Last five Years
Moving Traffic Violations (Last Five Years)
Driver's License Number
State
Marine Insurance Quote Form

Limits

Hull Market Value	$
Deductible	%
Dinghy	$
Liability Limit	$
Trailer	$
Personal Effects	$

Additional questions or comments?

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