Tuttle & Traina Insurance Agency, Inc.

Surety & Insurance Services

Richard C. Traina

William B. Tuttle

Thomas D. Moylan

Raoul Cormier
44 Main Street, Post Office Box 489, Sterling, MA 01564
Phone: (978) 422-7700    Fax: (978) 422-8106

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Boat Insurance

 Please completely fill out the form below, submit it to us, and we will be in touch with you shortly with your quote.

Personal Information
 
Name:
Address Line #1:
Address Line #2:
City:
State/Province:
Country:
Zip/Postal Code:
Day Time Phone Number:
Night Time Phone Number:
Best Time To Call:
E-Mail Address:
Preferred Method Of Contact:
Occupation:
How Long At Present Job:
SS/License Number:
We need your SS/license number in order to do an SDIP check and properly establish your rates.
Have you had any judgments, liens, or bankruptcies in the last 7 years?

If yes to the above question please explain just below.
 

Current Insurance Information

 
Company Name:
Policy Expiration:
Premium Amount: $ (Optional)
Current Coverage Or Bodily Injury Amount: $
Continuously Insured For The Last:
Have you ever had insurance cancelled, denied, or non-renewed?
If yes why?

Boat/Yacht Information

 
Make:
Model:
Year:
Horsepower:
Type Of Engine:
Number Of Engines:
Gas/Diesel:
Top Speed:
Boat/Yacht Style:
Length:
Beam:
Boat/Yacht Is Kept:
Lay Up Period Beginning:
Lay Up Period Ending:
Operated In The Waters Of:
This Boat/Yacht Has A Trailer: $
This Boat/Yacht Has A Dinghy: $
Safety Equipment:
(Example: Radar, Loran, GPS, or Halon.)
If This Boat/Yacht Is Not Kept At The Above Address, Please Provide The Information Below:

City: State: Zip:


Coverage Desired

 
Hull & Equipment Personal Effects Liability Coverage
$ $

Driver #1 Information

 
Name Relation Date Of Birth Sex
Self
Marital Status Courses Completed In The Last 3 Years
# Of Years Of Boating Experience # Of Years As A Boat Owner Previous Boats Owned
Driver #1 License Information
License Number: State: Years Licensed:

Driver #2 Information

 
Name Relation Date Of Birth Sex
Marital Status Courses Completed In The Last 3 Years
# Of Years Of Boating Experience # Of Years As A Boat Owner Previous Boats Owned
Driver #2 License Information
License Number: State: Years Licensed:

Driver #3 Information

 
Name Relation Date Of Birth Sex
Marital Status Courses Completed In The Last 3 Years
# Of Years Of Boating Experience # Of Years As A Boat Owner Previous Boats Owned
Driver #3 License Information
License Number: State: Years Licensed:

Driver #4 Information

 
Name Relation Date Of Birth Sex
Marital Status Courses Completed In The Last 3 Years
# Of Years Of Boating Experience # Of Years As A Boat Owner Previous Boats Owned
Driver #4 License Information
License Number: State: Years Licensed:

Driver History

 
Please list ANY convictions for ANY driver convicted of moving traffic violation in the past 3 years.

 
Driver # Date Of Incident Type Of Conviction Speed Over The Limit
mph
mph
mph
mph

Please list ANY driver who has had license suspensions, revocations, or driving under the influence convictions.

 
Driver # License Suspended Or Revoked? D.U.I. Conviction For?

Please list ANY driver involved in accidents, regardless of fault, in the past 5 years.

 
Driver # Date Description Cost Injuries / At Fault
$
$
$
$

Additional Comments

 
Please leave any comments or additional information here.

 

By clicking the button below I agree to understand that this is for quote purposes only and is in no way intended to act as an application or binder.