/ Orange Insurance LLC
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Watercraft / ATV Insurance Questionnaire

Please fill out this form (type, re-save and email it back if possible) to the best of your knowledge and ability and then we can get on the phone to go over any questions. (You can “TAB” over to get from question to question.)

{ Contact Information }

Name:
Address:
Address 2 (if applicable):
Home #:
Cell #:
Work #:
Fax #:
County:
City/State/Zip:

How Long at This Address:
Email:
Requested Time to Call or Email:

{ Watercraft/ATV & Trailer Information }
WATERCRAFT/ATV (Answer Where Applicable):

VIN#:

Hull # (if applicable):
Year:
Make:
Model:
Length:

Engine Size (HP):

Engine Brand:

Fuel (Gasoline, Diesel or Battery):

Fuel Tank (Fiberglass or Metal):

Maximum Speed:

Odometer (approx. hours):

Type of Power:

InboardOutboard Inboard/Outboard Waterjet Sail

Type of Hull:

Cabin Cruiser Open Cockpit Sailboat Pontoon

Bass/Fishing Personal Watercraft Ski

Hull Material (Fiberglass, Aluminum, Wood, etc.) (if applicable):

Hull Design:

Flat Round Vee Catamaran

Continued on the next page…

Date Purchased:

Cost New: $

Value Now: $

Date of Last Survey (if applicable):

Owner’s Experience with Boats / ATV’s (5 years, 10 years, etc.):

Type of Owner’s Experience (Pleasure, Power Squadron, USCGA, Other Education):

Waters Navigated (Watercraft); (Inland, Atlantic, Pacific, Great Lakes, etc.):

Terrain Navigated (ATV); (Hills, Forest, Dunes, Rock, etc.):

Storage (Summer) Location: Dry Wet

Storage (Winter) Location: Dry Wet

OTHER QUESTIONS (If Applicable) (Check Box Below (“x”) for Yes):

Is The Boat Chartered To Others?: How Often?: Where To?: Duration: Purpose:

Is The Boat Used Commercially or For Business Purposes?:

Is The Boat Used for Racing?: How often?: Duration of Race:

Is The Boat Used for Waterskiing?: How Often?:

Does The Applicant Employ a Paid Crew?: How Many Full-Time: How Many Part-Time:

Any Sleeping Facilities?:(Provide Number Of Beds):

Any Existing Damage to The Boat?:

Is The Boat Used as a Primary Residence?:

Any Additional Owners Not Listed as The Named Insured?:

EQUIPMENT (If Applicable) (Check Box Below (“x”) for Yes):

Bilge Pump:

Cooking Stove:

Fume Detector:

CO2 / Chemical Systems:

Fire Extinguishers: How Many:

Depth Sounder:

Fish Finder:

Radar:

Radio Direction Finder:

Ship-to-Shore Radio:

Anti-Theft Devices: What Type:

Heater:

Air Conditioning:

Refrigerator:

TENDER / LIFE BOAT (If Applicable):

VIN/Serial#:

Year:

Make:

Model:

Length:

Continued on the next page…

TRAILER(If Applicable):

VIN/Serial#:
Year:
Make:
Model:

Length:

Axles (1, 2, etc.):

Wheels (2, 4, etc.):

Date Purchased:

Cost New: $

Value Now: $

{ Property, Owner & Policy Information }

Ownership Status: Own Vehicle Loan Lease / Loan

If Lease or Loan, Provide Lien Holder Information:

•Lien Holder Name:

•Lien Holder Address:

•Lien/Loan #:

Resident Type: Own Rent
Occupation:
Education: High School GED Associates Bachelors Masters

Trade/Vocational Other:

Did You Have Boater’s Education Classes (Y/N): Yes No
Driver's License #:
Owner’s D/O/Birth:

Owner's Age:

Owner's Gender:

Owner's Marital Status:

Owner's SSN:

  • Providing your SSN will get access to more carriers and a more accurate quote.
  • Call 206.774.7867 to leave on voicemail if you do not want to write it down.

Owner's Self-Credit Rating: Excellent Good Fair Poor

{ Current Insurance Information }

Copy of Your Current Policy (if Available): Provide is Possible.

Does This Replace an Existing Policy? (Y/N): Yes No

Expiration Date of Existing Policy:

Current Annual Premium: $

Current Insurance Carrier:

Length of Time Insured with This Carrier:

Number of Years Continuously Insured Overall:

Any Recent Claims (Y/N)?: Yes No

If Any Claims, Number of Claims in Past 3 Years:

Continued on the next page…

{ New Insurance Information }

PHYSICAL DAMAGE:

Hull, Permanent Equipment & Tender: $

Unattached Equipment: $

Trailer: $

Personal Effects: $

Emergency Assistance / Towing: $
Hurricane Haul-Out: Yes No

If Hurricane Haul-Out, How Much Coverage: $

LIABILITY:

Desired Bodily Injury Coverage (each person/each accident):

$ 50/100 100/300 250/500

Desired Property Damage Coverage (each accident):

$ 50 100 250 500

Desired Underinsured Bodily Injury Coverage (each person/each accident):

$ 50/100 100/300 250/500

Desired Underinsured Property Damage Coverage (each accident):

$ 50 100 250 500

Desired Medical Payments Coverage (Including Water Skier):
$ 1k 2k 3k 4k 5k

Desired Additional Special Coverage (If So, Please Specify): Yes No

Type of Additional Special Coverage:

Desired Effective Date of New Policy:

Desired Deductible Amount:

$ 250 500 1,000

Multi-Policy Discount; for example - Home and Auto with the Same Carrier (Y/N):

  • Yes No

RESIDENTS, DEPENDANTS (Licensed or Not) and REGULAR OPERATORS:

#1:

Name:

Gender:

Marital Status:

D/O/Birth:

Occupation:

Driver’s License Number:

Driver’s License State of Issue:

SSN:

Continued on the next page…

#2:

Name:

Gender:

Marital Status:

D/O/Birth:

Occupation:

Driver’s License Number:

Driver’s License State of Issue:

SSN:

{ Additional Coverage Interests }

Health Insurance: Yes No

{ Additional Comments/Notes (If Applicable) }

Once we get all of this information, we can get you a price indication within 12-24 hours and a firm, bindable, quote within 24-48 hours.
As a reminder, let me know if you need any other insurance needs. We handle it all; Property & Casualty, Life & Health, LTC, Surety Bonds, Aviation and more! Everything for your personal life and business ventures... (and you will often get discount for multiple policies with the same carrier)

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