Michael L. Hodge

e: info@mlhodgeinsurance.com

Toll Free: 866.921.8479

p: 661.295.8905

c: 818.590.5698

f: 661.554.7190

22934 1/2 Lyons Ave

Santa Clarita, CA 91321

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Name
DOB
Address

Occupation
City/St/Zip
Home Phone
Work Phone
Email
FAX
Boats Owned

Comments:
Detailed Information:
Boating/Sailing/Safety Classes
Other Experience
Previous Losses (3 Yrs)
Current Insurance Company
Name of Lender
Marina addt'l insured
Boat Name Moorage Location
Builder Year
Type Max Speed
Engine Manufacturer Engine Year
Single/Twin    
Last Survey Date Survey Done By
Market Value Replacement Value

Auto Halon/CO2

VHF

SSB

  

Depth

GPS

Radar

  

WeatherFax

Other Nav

      
             
Tender:    Yr

Length

Make/Model

  
Outboard: Yr

H.P.

Make/Model

  
Navigation Limits
Paid Crew (if any)
Offshore Cruising/Racing Anticipated
Deductibles

1%

2%

 3% other
Hull Value  $
Liability  $
Personal Effects $
Medical  $
Tender/Outboard  $

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