Hartge Insurance Associates - We Specialize In Your Unique Insurance Needs

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Basic Information:

Target Effective Date:
Name:			Email:
Day Phone:			Evening Phone:
Address:			City, State, ZIP:
Date of Birth :

Experience

Number of Years As:

Boat Operator:		Boat Owner:

Previous Vessels Owned:

Courses

None	Basic Courses	US Power Squadron
USCG License	CG Aux	Other:
Claims in last 5 years:
Explanation of Claims:
Amount of Loss:

Yacht Information

Year:		Make:
Model:		Length:
Hull Material		Type:
Engine Make:		# of Engines
HP Each:		Top Speed:
Engine Type:		Fuel:
Mooring Location:
Use of Yacht:	Private Pleasure 6 PAC Bareboat Charter USCG Inspected	Other:
Navigation Area:
If lay-up needed please supply the following information:
Dates:		Ashore	Afloat
Last Out of Water Survey:
Is Captain/Crew Coverage Needed?		# of Captain/Crew
Is There a Bank Loan?

Coverage Needed

Hull Value:
Liability (P&I):	or Other
Personal Effects/Fishing Equipment:

Comments: