25124 Jefferson
St. Clair Shores, MI 48081
Phone 586-772-0650
Fax 586-772-8615
www.f-k-agency.com
marineinsurance@f-k-agency.com
 Agent's Name and Email
 Agency Name:     Agency Code:
 Name:
 Email:
 Insured's Name, Address & Zip Code
 Name:
 Address:
 Address:
 City:
 State:
 Zip:
 Phone: - -
 Effective Date:    
 Type of business   New   Quote
 Name of Yacht:
 Manufacturer:
 Model Name:
 Overall Length:
 Purchase Date:    
 Year Built:
 Engine: Single   Twin
 Total Horse Power:   Speed:
 Engine Type: Gas   Diesel
 Usage: Pleasure   Other
 Loss Payee Name & Address (Bank or Credit Union)
 Name:   N/A
 Address:
 Address:
 City:
 State:
 Zip:
 Navigation Territory:
 Coverage Requested
 Deductible:   1%   2%   3%   Other
 Hull Insured Value:
 Towing:
 Protection & Indemnity:
 Med Pay:
 Personal Property:
 Uninsured Boater:
 Pollution (Fuel Spillage) Limit: $500,000
Coverage Requested (cont)
Direct Bill:
Type of Yacht:
Cruiser Aux. Sailboat
Trawler Runabout
Hull ID#:
Material:
Principal Mooring
Marina:
City:   Zip:
Previous Insurance Carrier
Name:
No. of Losses:
Brief Desc:
Amount of Loss:
Lay-Up Location
Name:
City:   Zip Code:
From:   To:
Ashore:   Afloat:
Navigational Equipment
Built-in Fire Extinguisher   Depth Finder
Gas Fume Detector
Alarm System
Plotter   GPS
Carbon Monoxide Detector
Ship to Shore   Radar/Loran
Experience* (required section)
Number of Boating Years:  
Coast Guard     Power Squad
Other:
Prior Owned Boats (Length & Make):
Occupation:
D.O.B:      
Driver's License:
Date of Last Survey      
Other Information  
 Memo
 
 Dingy: Year: Make: Length: S/N: Value:
 Outboard: Year: Make: HP: S/N: Value:
 Trailer: Year: Make: S/N: Value:
As a normal part of the underwriting procedure, a routine inquiry may be made which will include information concerning charter, general reputation, personal characteristics and mode of living. Public Law 91-508 (Federal Fair Credit Reporting Act) requires that if such a report is made, upon your written request within a reasonable time after you receive this notice, additional information as to the nature and scope of the inquiry will be provided. I Understand that the above information, which is correct and complete to the best of my knowledge, is to the basis of insurance, if granted, but does not obligate me to accept the insurance nor the company