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Business Name:
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| Contact Name: |
| Address: |
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State |
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| Telephone# |
Fax # |
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| Current Insurance Company |
| Expiration Date |
| Quote Needed By: |
| Year Business Started: |
| Federal ID# |
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In order to receive a competitive quotation, please respond with the following information:
- Completed Application
- 4 Year Hard-Copy Loss Runs (If Available/Applicable)
- Copy of Current Dec. Sheets From Policy or Insurance Summary
- Brochure or Website Address
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| Property
Number of Premises:
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- Is business coverage desired? Yes No
- Is additional coverage needed for computers and software?Yes No
- Is coverage requested for piers/wharves/docks? Yes No
If yes, please provide the following:
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| Diagram: |
Number of Docks: |
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| Type of Construction |
Fixed floating |
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| Year (s) Built: |
Value ($) |
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| Boat Dealers: |
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| Annual Sales of Boats/Motors/Parts/Trailers |
$ |
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| Average Inventory Available for Sale |
$ |
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| Maximum Inventory Available for Sale |
$ |
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| Maximum Value In Transit At One Time |
$ |
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| Maximum Value On Exhibit At One Time |
$ |
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| Average Number (#) of Vessels In Inventory |
$ |
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Deductible Desired for Boat Dealers Inventory: $
List Major Manufacturers and Type of Craft Sold:
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| Marina Operators Legal Liability |
| Docking |
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| Number (#) of Slips Available |
| Maximum Value of Any One Vessel Docked $ |
| Annual Gross Receipts for Docking $ |
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| Fueling |
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| Annual Gross Receipts for Fueling $ |
| Total Annual Gallons Sold |
| Fuel Type |
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| Hauling/Launching (Not In Conjunction With Repair/Storage) |
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| Number (#) of Vessels Per Year |
| Maximum Value of Any One Vessel $ |
| Annual Gross Receipts $ |
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| Mooring |
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| Maximum Number (#) of Vessels Moored |
| Maximum Value of Any One Vessel $ |
| Annual Gross Receipts: $ |
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| Rental Boats |
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| Number # of Vessels |
| Annual Gross Receipts $ |
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| Boat Repair |
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| Average Value of Vessels Handled |
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Maximum $ |
| Maximum Number of Vessels at any one time |
| Annual Gross Receipts (Labor) $ |
| Annual Service / Repair Payroll $ |
| Store Sales |
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| Gross Receipts |
Food / Drink |
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| Storage |
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| Average Number of Vessels Stored |
Maximum |
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| Rack Storage Yes No |
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| How High (Feet) 2 3 4 |
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| Commercial Tools |
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| Employee Tools |
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| Amount of Coverage Per Employee |
Amount of Coverage Per Occurence |
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| Unscheduled Equipment:
Amount of Coverage
Maximum Value of Any One Item:
Scheduled Equipment: (List All Equipment Over $2500 To Be Covered)
by Manufacturer, Year Built, Serial #, Cost New, Limit Of Insurance
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| Owned Watercraft
List Owned Watercraft by Manufacturer, Use (Work/Rental), Type, Year Built, Length, Hull Model, Horse Power (HP), Value ($)
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Worker's Compensation: (If Coverage Desired, Please Read the Following)
- Current Experience Modification Worksheet
- Complete Below Information
List by Description, Annual Payroll ($), and Number of Employees
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| Automobile - Please provide the following information for all commercial vehicles:
Make, Model, Year, VIN#, Cost New ($)
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| Please provide drivers list that includes the following:
Driver Name, DOB, License #, State, Date Hired
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| Loss History - Please provide currently valued loss runs from the prior 4 years, if no losses type none and hit submit. |
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