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8500 Shawnee Mission Pkwy,
Suite 200,
Merriam, KS 66202
877-812-8216

Millennium Mariner Gold Insurance

Quote

Applicant Information

Name: *
Date of Birth: *
How did you hear about us? *
Address
Address2
City, State, Zip:
Phone:
Email: *
Are you a 6-pack Fishing Charter?
1. YesNo

Watercraft Information

Year *, Manufacturer *, Model *
Length * ft. in.
Beam
Hull Material
1. FiberglassAluminumWood
Total # of Engines *
Type *
1. HouseboatRunaboutPontoonDeckboat
  CruiserOther*
* If Other, please explain
Engine #1 * Make Model Year HP
Engine #2 Make Model Year HP
Engine Type *
1. OutboardInboardI/OJetSailAuxNone
Is your engine *
1. GasDiesel
Trailer * Year Make
Dinghy Year Make ft. in. $ Value
Dinghy Motor Year Make HP $ Value
Equipment
1. Depth/Fish FinderStainless Prop
  GPSAnti-Theft Trailer
  Anti-Theft BoatAnti-Theft Prop
  VHF RadioVapor Detector
  Auto Halon/CO2
Lay-up Dates to AshoreAfloat
Purchase Date *
Total Purchase Price *

Operator's Experience

Total years of boat ownership * Total years of operating experience *
Licenses Held
Previously owned boats Make Model HP Years Owned
Previously owned boats 2 Make Model HP Years Owned
Previously owned boats 3 Make Model HP Years Owned
Boating Courses Completed & Year
Any Auto or Watercraft Losses? *
1. YesNo
If yes: Date Circumstances $ Amt. Paid
Losses 2 Date Circumstances $ Amt. Paid
Losses 3 Date Circumstances $ Amt. Paid
Any Auto Violations
or Suspensions? *
1. YesNo
If yes: Date Circumstances
Violations 2 Date Circumstances
Violations 3 Date Circumstances

Intended Use

Vessel Uses *
1. Private PleasureLiveaboard (Primary Residence)6-Pack Fishing Charter
  Other* (details)
* If Other, please explain
Waters Navigated *
1. InlandGreat LakesCoastal
  Chesapeake Bay ONLYOther* (details)
* If Other, please explain
State where vessel is kept * Zip *

Coverage Desired

Hull & Equipment $
Engine #1 $
Engine #2 $
Trailer $
Dinghy Motor $
Towing Limit $ ($500 standard)
Personal Effects $ ($2500 included)
Watercraft Liability *
1. $50,000$100,000$300,000$500,000
  $1,000,000
Deductible *
1. 1% (Standard)2%5%

Optional Coverage

Optional Coverage
1. Platinum Endorsement What's this?
  Full-Time Captain and/or Crew -
  Pacific Cup Race Endorsement What's this?
  NAVIGUARD™ MBI What's this?
  
  Number of Individuals

Current Insurance

Issuing Company Exp. Date
Current/Renewal Premium $
Has vessel been continuously
insured for the past 12 months?
1. YesNo
If "No", please explain

Products
Find an Agent
Submit a Claim
- Property Claim
- Injury Claim
Boating Resources
Contact Us
- Personnel List
- Forms For Insureds
Online Payment
Privacy Policy
Sitemap

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