Lawrence Fox Agency Watercraft Quote Request

To Request Your Quote, Please Fill Out This Form Completely - Thanks!

This form can be faxed to 1-516-798-6413

OR printed and mailed to
Lawrence Fox Agency
PO Box 160
Massapequa, NY 11758.
You can submit this form NOW by filling it out then pushing "Submit Request Now" at bottom of page.

About the Owner of the Vessel:
First Name:

Last Name:
E-Mail:

Company:
Address 1:

Address 2:
City:

State:
Zip/Postal Code:

Date of Birth:
Home Phone:

FAX #:
Business Phone:

Occupation:

Marital Status:

Social
Security #:
About the Vessel:
Year of Boat:

Length:
Manufacturer:

Model:
Date of Purchase:

Purchase Price:

 

Year:HP(each):

 

Max Speed

 

Do you Live aboard?

Lay Up Period:
Extended Navigation Areas Florida Bahamas

Other:
Mooring/Marina:

Address:
City,State,Zip:

County:
Your Boating Experience:
Years As Owner:

Years as Crew:
Size of last boat:

Type Of last boat:
Current Insurer:

Expiration Date:
Premium:

State:
Boating Losses:

Boating Losses:
Other Operator:

Age:
Other Operator:

Age:
Boating Education:(check all that apply)

Coast Guard Course

Power Squadron CTF#:

Captains License

Equipment:(check all that apply)

Radar Loran GPS VHF Radio
 Depth Finder Fume Detector EPIRB
Life Raft Automatic Fire Extinguishing System System Type:

 

Portable Fire Extinguisher Tender
 Manufacturer:

Power:

Value:
Coverage requested:

Hull and equipment $
 Deductible:

Other liability amount $

 

Medical Payments Coverage:
 Uninsured Boater Coverage$

Trailer Coverage $
 Personal Effects Coverage $

Date of Last Survey:

Other:

Search words used to find us Thank you.
Special Instructions:

 

 

 

 

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