Boat Insurance Quote Sheet
Name: (Required)
Address: (Required)
City: State: ZIP:
Phone:
Fax: (optional)
E-Mail: (optional)
Date of Birth:
Marital Status: Single   Married   Divorced   Widowed

Drivers License State:
Drivers License #:
Have you taken a USPS Course? Yes  No
Have you taken a CGAUX Course? Yes  No

 

Boat Information

Location of Where Boat is Kept:
City:    County:    State:
Year:    Make:    Model:   
Engine Type: Diesel  Gas    Number of Engines:
Horsepower (Each Engine):    Maximum Speed:   
Type of Boat:      Navigation Area:  
Insurance Desired:  (If you would like to insure any of the below, enter its value)
Value of Hull and Machinery:
Trailer Value:
Dinghy-Tender Value:
Dinghy-Tender Outboard Value:
Liability:    Other:
Why are you choosing to obtain insurance? New Purchase   Renewal
Additional Information:
How would you preferred to be contacted? Phone  E-Mail   Mail  Fax
If we need to speak to you via phone, when is the best day and time to call?

How did you hear about tangotangotango.com?

   

Tango, Tango, Tango Insurance
1139-5 Jericho Turnpike
Commack, NY 11725 		Tel: 631-543-0500
Fax: 631-670-7642
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