Seahorse Agent Application

Agency Name

Address 1

Address 2

City

State

Zip

Phone

Fax

E-mail Address

Federal Tax ID

Principal(s) ((Name/Title))

Primary Contact for Boat Insurance

Primary Contact Telephone Number

Number of Employees

Agency Annual Premium

Approximate # of Boats Insured Annually

Annual Premium (Boat Insurance Only)

Average Hull Value

Current Boat Insurance Markets

Amount of E&O Coverage

E&O Carrier

How Did You Hear About Us?

Please attach current E&O declarations page, and any other information you feel important.

Please enter the security code pictured here.