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INET Insurance
27594 Detroit Road
Westlake, Ohio 44145

Phone 1-440-808-0706

Phone toll free 1-800-797-INET
 ( 4638 )

Fax 1-440-871-5672

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Please fill out the form below to the best of your ability. If you feel any of the information requested would not be needed feel free to leave the space blank and then click on submit or fax to:
INET Insurance at 440-871-5672.

Or for immediate assistance please call.

Phone toll free 1-800-797-4638

Phone               1-440-808-0706

USA Country Code is 011

OWNER INFORMATION
Name:
Address:
City:
State:
Zip:
Date of Birth:
Present
Insurance Company
:
Exp Date:
Premium:
Work Phone:
Home Phone:
Fax:
Email Address:
Occupation:
Years of
Boating Experience
:
Length and Make of
Previous Boats Owned
:

Courses & Membership: USPS
USCG
ACBS
Yacht Club
Motor Vehicle Driving Record, Past 5 Years:

BOAT INFORMATION
Vessel: Year: Length:

Make: Model:


Hull Material:
Max. Speed of Vessel:

Engines: Number: HP (Each):
Eng. Mfg.:


Equipment: VHF
Depth Finder
Loran
GPS
Radar
Burglar Alarm
Auto Fire Ext.

USE OF BOAT
Use: Pleasure
Charter
Mooring Location: City: State:

Name of Marina:


Navigation: Atlantic
Gulf
Great Lakes
Chesapeake
Pacific
Bahamas
Caribbean
Inland Waters - State of:
Other - Explain:

Layup Dates From/To: -
Losses: Date, Type & Amount Paid:

COVERAGE REQUESTED
Coverages: Hull & Equipment Value:

Deductible: 1% 2%


P&I Liability:
Paid Crew: Yes No Number:
Trailer:
Dinghy/Tender:
Survey Available: Yes NoSurvey Date
Vessel Purchase Date:
Purchase Price:

 

1999 - 2017 INET Insurance
All rights reserved

INET Insurance
27594 Detroit Road
Westlake, Ohio 44145

Phone 1-440-808-0706

Phone toll free 1-800-797-INET
 ( 4638 )

Fax 1-440-871-5672