Gamboa & Morton Insurance Agency
California Insurance License # 0656933

Boat Insurance

Quote Request Form

Tel: (415) 282-5888

for California Residents & International Tourists

Let us help you with our expert knowledge & experience!

Please contact me to see if I am eligible for company hidden discounts!

This process does not bind coverage!



How did you find us? URL or Search Engine Name:
Internet Newspaper Ad Radio Ad A Friend Family Other: Specify
Have we quoted you before?  No Yes  No  If yes, when? Product(s):                                                                                    mm/dd/yyyy
Are you currently or previously insured with us? No Yes    Insurance Product(s):

Applicant Name ( Boat Owner or Applicant for Non-Owner Policy)
Mr. Mrs.  Miss Ms.
 First Name: Middle Name: Last Name:

III, Jr.
 
Email Address:  Nation: County:
USA Canada Mexico Other:
Telephone Numbers:
Home: Work: Fax: Back #
Address Line 1:

Street #

Street Name

Suite or PO #

Address Line 2:

City

Province/State:

Zip Code

 Zip Code +4

 Primary and Additional Boatsman or Boat Pilot Information:

Driver Names:

Sex/Gender:

Date of Birth:

Marital Status:

Occupation:

1. First Boatsman--Primary
Name: First, Middle & Last



Male
Female
SR-22
SR-1P

Date of Birth:

MM/DD/YYYY
//

Marital Status:
Military
Government
Civilian: (specify)
2. Second Boatsman
Name: First, Middle & Last


Male
Female
SR-22
SR-1P

Date of Birth:

MM/DD/YYYY
//

Marital Status:
Military
Government
Civilian: (specify)
3. Third Boatsman
Name: First, Middle & Last


Male
Female
SR-22
SR-1P

Date of Birth:

MM/DD/YYYY
//

Marital Status:
Military
Government
Civilian: (specify)
4. Fourth Boatsman
Name: First, Middle & Last

Male
Female
SR-22
SR-1P

Date of Birth:

MM/DD/YYYY
//

Marital Status:
Military
Government
Civilian: (specify)
5. Fifth Boatsman
Name: First, Middle & Last


Male
Female
SR-22
SR-1P

Date of Birth:

MM/DD/YYYY
//

Marital Status:
Military
Government
Civilian: (specify)
6. Sixth Boatsman
Name: First, Middle & Last


Male
Female
SR-22
SR-1P

Date of Birth:

MM/DD/YYYY
//

Marital Status:
Military
Government
Civilian: (specify)

Additional Driver Information for Discounts

Boatsman

#

Boating Training 

Years Boating Experience:
Calif. US Foreign

Good
Student

Non-Smoker 

Student Away at School 

1
 

2
 

3
 

4
 

5
 

6
 


Please list all violations and accidents (including not-at-fault accidents) for the last 3 years:

Driver
#

Name

 Violation CODE #

Accident Description
Violation Description

Violation Date
//Conviction Date
//MM/DD/YYYY

Driver
#

Name

 Violation CODE #

Accident Description
Violation Description

Violation Date
//Conviction Date
//MM/DD/YYYY

Driver
#

Name

 Violation CODE #

Accident Description
Violation Description

 Violation Date
//Conviction Date
// MM/DD/YYYY

Driver
#

Name

 Violation CODE #

Accident Description
Violation Description

 Violation Date
//Conviction Date
// MM/DD/YYYY

Driver
#

Name

 Violation CODE #

Accident Description
Violation Description

Violation Date
//Conviction Date
// MM/DD/YYYY

Driver
#

Name

 Violation CODE #

Accident Description
Violation Description

Violation Date
//Conviction Date
// MM/DD/YYYY

Driver
#

Name

Violation CODE #

Accident Description
Violation Description

 Violation Date
//Conviction Date
// MM/DD/YYYY
License Status by Boatsman/Driver Number:
 1               2               3              

 4               5               6              


Your comments about violations, accidents and convictions:

Boat(s) Description(s) -- Please Be Specific

Boat
1

Year

MakeModelSub-Model

Max. Speed
(Miles/Hour)
Horsepower

Boat StyleHull TypeConstruction Type
Value
Original
Current
Replacement
Blue-Book
$

Boat Serial #

Boat
2
Year

MakeModelSub-Model

Max. Speed
(Miles/Hour)
Horsepower

Boat StyleHull TypeConstruction Type
Value
Original
Current
Replacement
Blue-Book
$

Boat Serial #

Boat
3
Year

MakeModelSub-Model

Max. Speed
(Miles/Hour)
Horsepower

Boat StyleHull TypeConstruction Type
Value
Original
Current
Replacement
Blue-Book
$

Boat Serial #

Boat
4
Year

MakeModelSub-Model

Max. Speed
(Miles/Hour)
Horsepower

Boat StyleHull TypeConstruction Type
Value
Original
Current
Replacement
Blue-Book
$

Boat Serial #

Boat
5
Year

MakeModelSub-Model

Max. Speed
(Miles/Hour)
Horsepower

Boat StyleHull TypeConstruction Type
Value
Original
Current
Replacement
Blue-Book
$

Boat Serial #

Boat
6
Year

MakeModelSub-Model

Max. Speed
(Miles/Hour)
Horsepower

Boat StyleHull TypeConstruction Type
Value
Original
Current
Replacement
Blue-Book
$

Boat Serial #

Boat Use & Discounts

Boat Usage

Primary Boatsman Name



Liability & Uninsured Motorists Coverage:

A. Liability Limit - Bodily Injury: [Required by Law]
B. Liability Limit - Property Damage: [Required by Law]               
C. UMBI--Uninsured/Underinsured Motorists Bodily Injury Limit:      (Not more than liability limit (A.) or company maximum.)
D. UMPD--Uninsured/Underinsured Motorists Property Damage: 
E. MEDPAY--Medical Payment Limits-First Aid for You & Your Passengers:



Physical Damage Coverage & Deductibles:
Required by Loan/Lease Companies
Notes on Choosing a Deductible:
If you are a good driver, choose the highest deductible you could afford if in an accident;
your rates will be substantially lower!

Boat #1: Comprehensive Collision 
Boat #2: Comprehensive Collision 
Boat #3: Comprehensive Collision 
Boat #4: Comprehensive Collision 
Boat #5: Comprehensive Collision 
Boat #6: Comprehensive Collision 


Include Coverage for Towing & Labor? Yes No
Include Rental Reimbursement Coverage? Yes No

Additional Information:

Do you currently have insurance? Yes No
Who is you current auto insurance company? 
When does your current policy expire?