Paquin & Carroll Insurance

Boats and Yachts: Premium Quotation Request

Contact Information
* First Name
* Last Name
* Address
Address 2
* City
* State
* Zip
* Day Phone
Evening Phone
Fax
* E-Mail

Group Affiliation:

Vessel Description
* Make
* Model
* Year
* Length (In Feet)
Name

* Hull Material	Fiberglass Steel Aluminum Other:

* Engines	Gas Diesel
Horsepower

Safety Features
Auto Halon	Yes No
Auto CO₂	Yes No

Navigation	Inland Coastal Other

Operator Information
Operator#1
* Operator Name
* Date of Birth
* Years Licensed
* Drivers License Number
* Boating Courses

Operator#2
Operator Name
Date of Birth
Years Licensed
Drivers License Number
Boating Courses

Please list all accidents (including not-at-fault accidents) and violations for the last 3 years:


Coverages
Please state below the limits of coverage you desire:
* Deductible
* Hull and Equipment
Tender and Outboard
Personal Effects
Medical
* P & I Liability

Additional Information
* Do you currently have insurance?Yes No
Current policy expiration date?

Any additional comments:

How would you prefer to be contacted?
Email
Phone
Postal Mail
IMPORTANT Submitting this request form does not guarantee coverage. We will acknowledge your information request within one business day, and will advise you on your coverage options. Please check the button below before submitting this form.
*I understand that submitting this request form does not guarantee coverage.