W.R. HODGE NS MARINE INSURANCE, Inc.
Yacht Insurance Specialists
Global Yacht Insurance


2015 SW 20th Street
Suite 100
Fort Lauderdale, FL 33315
(954) 523-6867
(800) 990-WAVE (9283)
(954) 523-6488 Fax
At Lauderdale Marine Center


Professional Yacht Insurance Agent
Yacht Insurance Quote


Please complete the following in as much detail as possible to assure we can provide you with the most competitive rate, or phone us at 1-800-990-WAVE for immediate quote on our yacht policy or other forms of marine coverage.
*E-mail address required.
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APPLICANT'S PERSONAL INFORMATION
Full Name:
Address:
City:
State/Province:
Zip code/Postal zone:
Country:
Drivers License State and Number:    
Telephone:
Fax:
*E-mail:
Occupation:
Date Of Birth:
Years of boating experience:
Size and builder of previous boats owned:
Are course/member certificates available? Power Squadron USCG Auxillary
USCG Captain License None
Motor vehicle driving record past 5 years:
Are there other operators of this vessel? Yes No
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VESSEL INFORMATION
NAME OF VESSEL:
YEAR:
MANUFACTURER/BUILDER:
If your builder is not listed above please add your builder here:
MODEL:
TYPE OF VESSEL:
LENGTH:
PURCHASE PRICE OF VESSEL:
DATE OF PURCHASE:
FLAG: US Foreign
MAXIMUM SPEED:
HULL TYPE:
HULL MATERIAL:
ENGINES: NUMBER: FUEL TYPE:
HORSEPOWER EACH.........
MANUFACTURER..............
DRIVE TYPE...
AUTO FIRE EXTINGUISHERS:
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VESSEL USAGE AND LOCATION
PRIVATE PLEASURE PART TIME CHARTER FULL TIME CHARTER
IF CHARTER- MAX. NUMBER PAYING PASSENGERS/GUESTS:
WHERE IS THE VESSEL MOORED?

NAVIGATION LIMITS
Waters navigated next twelve months:
If vessel is south of North Carolina June through November, where navigated and berthed?
Is vessel ever laid-up? Yes No
What months is she out of commission? to
If laid up, is vessel stored:
Will anyone be living aboard the vessel during the policy period? Yes No
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PRESENT AND PAST INSURANCE INFORMATION
PRESENT INSURANCE CO.:
EXPIRATION DATE OF POLICY:
CURRENT PREMIUM:
OWNED BOATS SINCE:
Have you had any yacht insurance claims in the past 10 years? Yes No
Please enter the year, amount, and a brief outline of the loss/claim.

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COVERAGES REQUESTED
Hull and equipment value:$
Tender/Dinghy $ Year
Trailer............ $ Year
Survey Available: Survey Date
Survey conducted:
LIABILITY COVERAGE  (Protection and indemnity)
Paid Crew Number of Paid Crew:
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Comments
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