Marine Insurance Massetti Marine Insurance "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Name* First Name Last Name Phone*Date of Birth* Email* Address Address Line 1 Address Line 2 City State Zip Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Mailing Address (If different from above) Are You a Homeowner? Yes No Vessel DetailsVessel NameModel YearManufacture/ModelPurchase Date (MM/YY) Present Value (USD)Hull ID NumberEngine MakeNumber of EnginesTotal HorsepowerFuel TypeLength Overall (Feet)Purchase Price (USD)GPS Tracking Device:If yes, please provide full manufacturer and model details.Vessel Registration Country:Is the Vessel Chartered to Others With a Captain? Yes No Is the vessel used to carry fare paying passengers under charter? Yes No Current Survey Available?Max. file size: 1 GB. Trailer DetailsManufacturerYearPresent ValuePreviously Owned VesselsCompletion of Any Boat Safety Courses? ( Please List )Any accidents, claims or losses in the past 5 years? Yes No Have You or Any Named Operator Ever Been Convicted of a Criminal Occurrence or Pleaded No Contest to a Criminal Action (Including but Not Limited to Dui/dwi)? Yes No Vessel Mooring Location if Different From Home Address:How is the Vessel Stored?Dry StackLiftSlip/DockTrailerWill the Vessel Be Used Outside of South Florida Waterways and Coastal Navigable Waters? Yes No Additional InformationPlease List All Additional Operators (Name, Dob, Boating Experience)How Did You Hear About Us?ReferralSocial MediaGoogleOtherSMS Text Messaging* By Checking this box, you agree to receive SMS text messages from Santa Fe Insurance Tag & Title, Inc. related to conversational purposes. You may reply STOP to opt-out at any time. Acknowledgement* By proceeding with obtaining a quote from Santa Fe Insurance Tag & Title, Inc., you consent, where applicable, to allow us and our affiliated insurance brokers/carriers to obtain and review your credit-based insurance score, motor vehicle report (MVR), and claims history as part of the insurance quoting and underwriting process. This information will be used solely to determine your eligibility and rates for insurance, adhering to the Fair Credit Reporting Act (FCRA) and other relevant laws, ensuring the confidentiality and security of your personal information. Additionally, by providing your contact information you agree to our communication policy, which allows us to contact you regarding your insurance quote via phone, email, or recorded voicemails. You may opt out of these communications at any time. All the above information is accurate and true to the best of my knowledge.
