February 23, 2012
Martin Terry & Associates, Ltd.

Premium Quotation Request Card

Personal Information
Date
Name *
Email
Street Address
City
State
Zip
Business Phone
Home Phone
Vessel Information
Vessel Information
Builder
Type
Year Built
Length
Engine H.P.
Engine Diesel  Gas
Equipment
Equipment
Equipment VHF  Loran or Radar  Depth Finder  Auto CO2
Insurance Coverage Requested
Insurance Coverage Requested
Hull Value 1%  2%
Watercraft Liability $300,000  $500,000  other
Medical Payments ($2,000 up to $5,000)
Navigation Area
Navigation Period 8 Months  12 Months
Mooring Location
Mooring Location Pier  Buoy
If vessel is used commercially, please describe operation
Operation Information
Operation Information
Years of Boating Experience
Loss Experience Past Five Years
Miscellaneous Information
Miscellaneous Information
Currently Insured By
Is Vessel for Sale? Yes  No
Purchase Price of Vessel $
* = Required Field
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© 2010 All Rights Reserved Martin Terry & Associates, Ltd. 
  182 Duke of Gloucester St. Annapolis MD, 21404-1788
(410) 268-2437 Fax (410) 626-0341