Oversea Insurance Agency, Inc 1274 Scott Street. San Diego, CA 92106 619.222.1111 E-mail: Inquiry

To ensure an accurate quote, please fill out all of the information below.

Name Insured
Address
City, State
Country
Zip Code
Phone Number
Fax Number
E-mail
VESSEL DESCRIPTION
Material	Fiber Glass Wood Aluminum Other
Yr. Length Manufacturer Model
Engine	Single Twin
	Gas Diesel
Built In	CO2 Halon None
Yr. HP (each) Manufacturer Top Speed (knots)
Navigational items	VHF Radar Auto Pilot Depth Finder Loran GPS SSB Weatherfax
Primary Area of Navigation	So. Cal No. Cal SeattleHawaii Other
Vessel Location (mooring location)	(Additional Insured) Yes No
Extended Navigation (trip)	Date of Departure Date of Return
Brief Itinerary
COVERAGES
Purchase Price
Date of Purchase
Insured Value
Liabilty Limit
Tender/OB Value:
# of Paid Crew
Date of Last Survey	Dry Affloat
Surveyor
Market Value
Replacement Intended Use
Type of Charter
How did hear of us?	Search Engine Advertisement Friend
OPERATOR INFORMATION
Occupation
Previous Boats Owned
List Sizes and Manufacturers
Courses Taken
List Losses w/in 5 years
Years Boating Exp.
Age
Live Aboard	YesNo
Previous Insurance Co.
Expiration Date
Expiration Premium
Loss Payee
Other Comments
NOTE: Please type in additional information in the box below.