Coleman Marine - Quote Request Form

Basic Yacht Information
Yacht Owner's Full Name
Yacht Owner's Date of Birth
Married? Own Home or Condo?
State Zip Code
E-mail Address
Please Contact me by:
Work Telephone
Home Phone
Vessel Details
Length Model
Maximum Speed Total Horsepower
Registration Doc#
Type Contruction
Date Purch Purchase Price
Your Yacht Engine Manufacturer/Model
Year Built Fuel Type

Vessel Power Type (Motor)

Your Current Insurance Carrier
Current Insurance Expiration Date
Personal Data  
Years Ownership Experience Years Operating Experience
Previously Owned Vessels
(Size & Type)
Boating Courses Completed
Loss History
(Include Dates, Cause and Amounts)
Other Operators  
Name D.O.B. Experience
Occupation Boating Courses
Name D.O.B. Experience
Occupation Boating Courses
Your Vessel's Navigation Area
Include the Bahamas in this area? Select one
Lay Up From To Lay Up Type: Afloat Ashore
Primary Mooring Location?
Navigation & Safety Equipment Please Check All That Apply
VHF Radio
Auto Pilot
Depth Finder
Anti Theft Devices
Sat Navigation
Fume Detector
Dinghy Manufacturer
Length of Dinghy Purchase Date Price
Dinghy Outboard Manufacturer
Dinghy Outboard Price
Dinghy Outboard HP
Trailer Model/Manufacturer
Tralier Year/Price
Current Survey Date of Current Survey
  Survey Type
Loss Payee Information  
Mortgagee Name
Mortgagee Address
Miscellaneous Comments
Is this Yacht ever chartered to others?
If Answer is Yes, Please Explain
Is this Yacht used for commercial purposes? Explain Please
No. of Trips Avg Number of Passengers
Do you employ a paid captain
or crew?
How Many? Captains and/or Crew
Has any carrier cancelled or refused yacht insurance? Explain
Is this Yacht used for racing?  
Requested Insurance Coverages  
Yacht Hull and Equipment Select Deductible
*Dinghy Coverage  
Trailer Amount  
Liability(P&I) Amount  
*Personal Effects$5,000  
Uninsured Boater  
*Vessel Assistance/Towing $1000>>>
*Hurricane Haul Out  
Sail Boat Club Racing Permissable? >>
*Fishing Equipment  
*Electronics Deductable  
Additional Comments / Questions

Please enter the correct form validation code below.


Survey Requirements:
For Yachts over 10 years of age, we require a survey less than 3 yrs old.
Yachts less than 10 years, no survey required (unless requested by company).

Thank You for allowing Coleman Marine, Inc. to quote your policy!

Ph 904.824.8880    |    Fax 904.824.8580
3036B Harbor Drive   |   St. Augustine, FL 32084