Mike Aylward Insurance Agency Fairview Oklahoma

In order for Aylward Insurance Agency to give you the fastest and most accurate marine insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes only!

Results of this form offer only an indication of premium amount. Many of the companies that we represent require a credit / claims history report. We will not ask for this information when providing the initial quote. However, we want you to know that this is required by many companies. We understand and respect your privacy and this information will not be obtained without your permission.

General Information

Name:
Address:
City, State Zip:	,
Home Phone:
Work Phone:
Email: (Required)

Current Boat Insurance Company (not agency):

Company Name:
Policy Exp. Date:	/ / (mm/dd/yyyy)
Currently Not Insured:

Boat #1

Year:

Manufacturer:

Model:

Length:

Type of boat:

Motor Information:

Motor Make:

Waters Navigated:

If other, please describe:

Boat Condition:

Number of Operators:

Jet propelled:

Yes
No

Age of Primary Operator:

Marital Status of Primary Operator:

Age of Alternate Operator:

Marital Status of Primary Operator:

Boat Storage:

Garage	Apartment Parking Lot	Marina
Driveway/Yard	Locked Building	Other

Boat #2

Year:

Manufacturer:

Model:

Length:

Type of boat:

Motor Information:

Motor Make:

Waters Navigated:

If other, please describe:

Boat Condition:

Number of Operators:

Jet propelled:

Yes
No

Age of Primary Operator:

Marital Status of Primary Operator:

Age of Alternate Operator:

Marital Status of Primary Operator:

Boat Storage:

Garage	Apartment Parking Lot	Marina
Driveway/Yard	Locked Building	Other

Operator History

Has the operator of this craft recieved any of the following in the past 3 years?

Accidents:

Yes
No

Violations:

Yes
No

License Suspension:

Yes
No

Motor Boat Losses:

Yes
No

Accidents in last 5 years, regardless of fault:

Yes
No

Comments