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IMIS Quote Request

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Please complete and submit the form below.  However, if you would rather complete the form offline, you may download a quote request form which can be completed offline and then mailed or faxed to us.

Personal Information

The personal information you provide will not be used by IMIS or the insurers it represents except for the purpose of determining the present availability and cost of the insurance you specify below.  Your contact information will not be used by us or others to contact you again at a later time unless you choose to have IMIS arrange such insurance for you.

Name of applicant
Mailing address  


(Please include the city, state and postal code of your address, and, if it is outside the U.S.A., include the country.)
Telephone      Fax       E-mail 
Occupation (if retired please also indicate prior occupation)
Date of birth     Years boating       Years as boatowner  
Largest prior vessel (describe vessel and when owned and where operated)
Second largest vessel (describe vessel and when owned and where operated)
Boating courses taken (please also list any boating licenses held)

Place a check next to any of the following statements that are true:

I have been cited for a boating or motor vehicle violation in the past five years.
I have made an insurance claim against a boat or motor vehicle insurance policy in the past five years.
I have been denied an insurance policy by an insurance company for boat or motor vehicle insurance.
I have had a boating or motor vehicle license suspended or revoked.
I have been convicted of a felony.
Someone will operate the vessel on a regular basis without me aboard.
A captain or crewman will be hired to operate or assist in the operation of the vessel.

If any statement was checked please provide details of the relevant circumstances in the Comments section below.

Vessel Information

Owners (if other than applicant named above)
Name     Builder  
Model      Style  
Year     Length       Construction  
Place Built     Place Registered  

              (if other than vessel year)






Spars (if the vessel is a sailboat please specify the material of the spars)
Damage (please describe any existing damage or other faults of the vessel)
Survey (indicate date of latest professional survey and whether or not the vessel was ashore for this)

Usage Information

Type of use                            
Time of use    
Area of use     
of U.S.                     

Seasonal       Winter at:  

Coverage Information

Present insurer of vessel     Expiration date of policy  
Purchase cost of vessel     Date of purchase  
Estimated current value (if other than purchase cost)
Desired insurance amount (if other than current value)
Deductible                    (percentage of insurance amount)
Value of dinghy & motor (include in current value)
Value of trailer (include in current value)
Liability insurance               


Please use the space below to expound upon any of the information provided above or to advise us of any peculiar circumstances of which we should know.  If any use other than recreational was indicated above, please provide below details of the planned use.  Please also use the space below to specify any supplemental coverages in which you are interested. (multi-line field; carriage returns allowed)


Please let us know how you came to learn about IMIS:

Before submitting enter the validation code 3757 here:    

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Last edited October 24, 2014
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