Untitled Document

In order for us to provide an accurate quote, the insurance company requires detailed information. Please complete this application form. If you leave information blank it will only delay getting a valid quote to you for the coverage you are requesting.

Questions in red are required fields in order to provide a valid quote. However, questions in green may have to be answered to bind coverage. If you do not answer the questions in green now, you may be asked to provide such answers at a later date prior to binding coverage.

About You
1. Name (owner of the boat) 2. Company (if boat is owned by a business) 3. Address (address for receiving mail) 4. Occupation of Insured	5. Date of Birth 6. Home Phone 7. Work Phone 8a. Fax Number Email address
Additional Interests
If your boat is financed by bank/credit union, we must have the following information
9. Name of Lending Institution 10. Address	11. Loan or Account Number
About Your Boat
12. Boat Type (see menu options) 13. What have you named your boat? 14. Purchase Price 15. Is Boat Used for Racing? Yes No 16. Maximum Speed (of boat in MPH) 17. Boat Manufacturer 18. Boat Model 19. Hull ID Number 20. Construction Type (see menu options) 21. Length	22. Weight 23. Engine Make & Model 24. Number of Engines 25. Total Horsepower 26. Fuel Type (see menu options) 27. Port Engine Serial Number 28. Starboard Engine Serial Number 29. Engine Type 30. Turbo-Charged Engines? Yes No
About Safety & Navigational Equipment - A discount might apply for some of these items
31. Automatic Fire Extinguisher? Yes No 32. Fume Detector? Yes No 33. VHF? Yes No 34. Radar? Yes No 35. Loran? Yes No	36. SAT NAV? Yes No 37. Finder? Yes No 38. RDF? Yes No 39. EPIRB? Yes No
About The Tender
If there is no Tender, skip questions 40-43 If there is a Tender, check here then
About The Auxiliary Outboard
If there is no Auxiliary Outboard, skip questions 44-47 If there is a Auxiliary Outboard, check here then
About The Trailer
If there is no Trailer, skip questions 48-50
48. Make 49. Serial Number	50. Dollar Value
Navigation, Docking & Storage
51. Boat use (see menu options) 52. Waters navigated (see menu options) 53. Boat Laid Up (period of time when boat is not in use) 54. Do you live aboard? Yes No 55. If YES, how many months per year? 56. Name of Marina?	57. Describe docking 58. Describe storage 59. Where is boat stored? 60. Has boat been surveyed? Yes No 61. Date of Survey
Note: If your boat has been surveyed, fax copy to (248) 258-1972 or mail to: PCI/Marine Division 401 S. Old Woodward Suite 370 Birmingham, MI 48009
About Persons Who Operate Your Boat (Include yourself)
Operator #1 62. Name Birth Date Drivers License Number Boat Courses Completed Operates the boat what % of the time? Years experience operating a boat?	Operator #2 63. Name Birth Date Drivers License Number Boat Courses Completed Operates the boat what % of the time? Years experience operating a boat?
Operator #3 64. Name Birth Date Drivers License Number Boat Courses Completed Operates the boat what % of the time? Years experience operating a boat?	Operator #4 65. Name Birth Date Drivers License Number Boat Courses Completed Operates the boat what % of the time? Years experience operating a boat?
66. Enter name of any operator who has had any moving violations or accidents in the last 3 years 67. Have you ever been refused insurance? Yes No 68. If YES, explain	69. Have you experienced any claims in the last 5 years? Yes No 70. If YES, explain
About Your Current Coverage [If applicable]
If you have a boat insurance policy currently in effect or one that has recently expired, please provide the policy limits and Deductible for each of the following Hull & Equipment..Limit Deductible P & I Limits............Limit Deductible Med Pay................Limit Deductible Personal Effects.....Limit Deductible Uninsured Boater..Limit Deductible Expiration date of this policy
Effective Date of Coverage
We can bind coverage ONLY upon receipt of your completed application, payment and any additional information if requested. Make your check payable to Ponta, Castle & Ingram Agency Mail to 401 S. Old Woodward, Suite 370 , Birmingham, MI 48009
PLEASE READ THE FOLLOWING STIPULATIONS BEFORE CONTINUING Notice of insurance information practices: Personal information about you may be collected from persons other than you. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent or broker for instructions on how to submit a request to us. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties. Enter Applicant's Name and Today's Date: Name/Date Clicking the CONFIRM button below means that I (the Applicant listed above) have read this application and I declare that to the best of my knowledge and belief all of the foregoing statements are true: and that these statements are offered as an inducement to the company to issue the insurance policy for which I am applying. (Kansas: This does not constitute a warranty) CONFIRM - You must click this confirm button before you hit the send button below PCI Agency promises not to use this information in any manner inconsistent with the purpose intended. View the PCI Agency Privacy Statement.