	Kevin E. Severance Insurance Agency
	Ph: (281) 333-3100 - Fax. 866-796-0610

Marine Insurance

Please fill in the request form below.
Note that fields marked with a * are required entries.
When the form is complete, click on the "Send Request to Kevin E. Severance Insurance Agency" button.

Insured Information

Customer No.
Kevin E. Severance Insurance Agency

EMail Address *
(Quote will be returned to this address.)

Name of 1st Insured *

Company

Name of 2nd Insured

Address

City/State/Zip (all three fields required) *

County *

Phone Number (with Area Code) *

Social Security Number

Driver License

Vessel Information
Vessel Year (e.g. 1995) *	Vessel Make *
Vessel Model	Vessel Length (in feet - e.g. 30) *
Vessel Type *	Hull Const *
# of Engines* Engines Year *	Engine Make *
HP (one engine) *	Engine Type *
Fuel *	Vessel Weight *

Tender Information
Tender Year	Tender Length (feet)
Tender Make	Tender Engine Year
Tender Engine HP	Tender Engine Make

Trailer Information
Trailer Make	Number of Axles
Trailer Year

Underwriting Information
Use of Vessel *	Live Aboard *
Date of Purchase (mm/dd/yyyy)	Purchase Price $
Present Value $	Vessel Top Speed (e.g. 28) *
Automatic Firefighting System *
Moorage Location(Name of Marina, Residence)
Moorage Zip Code	Moorage City
Moorage County	Moorage State *
Navigation Area * If navigating in additional areas, please use comment section below to record additional areas.
Has vessel been surveyed?	If surveyed, give date (mm/dd/yyyy)

Crew Information
Paid Captain or Crew *	No. of paid Captain/Crew members
Full time Captain

Operator Information
Primary Operator
Name *	Date of Birth (mm/dd/yyyy) or Age *
Years Experience (e.g. 25) *	Boating Courses *
Largest previous Boat
Percent of Use %	Occupation
2nd operator
Name	Date of Birth (mm/dd/yyyy) or Age
Years Experience	Boating Courses
Percent of Use %	Occupation

Present Insurance Information
Losses in Last 5 Years *	Cancelled Insurance in the last 5 years *
Loss Date (mm/dd/yyyy)
If losses in last 5 years or refused insurance, provide details
Present Insurance Company
Expiration Date (mm/dd/yyyy)	Premium $

Coverage Required
Hull * $	Select Deductible Percent *
Engine 1 * $	If no engines or if included in the hull value, leave as 0 (zero)
Engine 2 * $	If no engines or if included in the hull value, leave as 0 (zero)
Trailer * $	If no trailer, leave as 0 (zero)
Tender * $	If no tender, leave as 0 (zero)
Tender Engine * $	If no tender, leave as 0 (zero)
Personal Effects * $
Medical Payments * $	Liability Limit * $
Towing *	Uninsured Boat Owners * $