This form is intended for the use of Texas residents only.
Use "Tab" to move from field to field

Name and Address:


Your Name

Address

Additional Info (Apt #, etc.)
,TX
City
Zip Code (Required)

E-Mail Address (Required)

Day Phone
Evening Phone
Fax Number

How would you prefer that we reply to you?

Marital Status:
Current insurance carrier? How Long? yrs
Policy Expires?
Birthdate:
SS# Drivers Lic#
Number of years experience Member of any boating association

 

Purchase price: Loss Payee:

Loss Payee(if applicable)

Name:
Address:
City: State: Zip:
Balance Due:

 

Has insurance ever been declined: If Yes, explain
List and detail any losses or claims

Watercraft Information

Year: Length: Model: Builder:
Hull Identification #: Name of Boat:
Hull Type:
Hull Material: If other:

 

Engine Information:

Engine(s)
Year: Manufacturer: How many engines? HP each:
Max Speed (MPH): Engine(s) Serial#:

 

Trailer Information:

Year: Length: MFG:
Serial #

 

Tender Information:

Year: Length: MFG:
Serial #

 

Tender's Motor

Year: Length: MFG:
Serial #

 

Equipment Information:

Loran? Radar? Halon?
GPS? Depth Finder? VHF?
Other:

 

Navigation

Coastal Waters? Inland Waters? Specify Waters
Vessel will be laid up Where:

 

Chartered   Ever used for water skiing?
If watercraft is in excess of 24 feet, is it ever transported over land?
How many miles?

 

Coverage Desired

Effective Period From to

 

  VALUES DEDUCTIBLE
Hull and Machinery
Outboard Motor
Equipment
Tender and its Motor
Trailer
Liability
Medical Payments
Overland Transp. (miles)
Uninsured Boaters
Personal Effects
Assistance/Towing

or

 

This web page is designed to allow the general public in the state of Texas to request quotations, and related information. The quotations that are returned to the requester are NOT binding policies; they do not guarantee insurability nor coverage upon receipt of quotation. The agent must have a signature and money to bind a policy. For exact numbers, definitions, or coverages of any terms discussed, please contact Tom Sorrels Boat Insurance Agency.