Quantum Marine Service Intake Form

First Name *

Last Name *

Address

City

Phone *

Email *

Date of birth (want a birthday promo sent to you? Add your birthdate below. )

Boat Name

Boat Year

Boat Make

Boat Model

Engine Make

Engine Serial Number #

Boat Registration Number #

Hull Number #

Standard Service or Diagnostic?

Describe what happened to your boat/engine...

Did anything else change before/during/after the incident?

Last time fuel was added (approx.)?

Last time boat was running well (approx.)?

When was the last service (approx.)?

What was the last major component to be replaced/fixed?

Add any additional Info that you feel we should know:

What should we do if we need to order a part but can't get a hold of you?

Contact me for ALL approvals (can lead to delays as we may need to order your part)

Spend up to $25 for necessary parts before contacting me

Spend up to $100 for necessary parts before contacting me

Do you have insurance? *

Yes, I have active insurance on my boat

No, I do not have insurance on my boat

I'm not sure, I need to confirm

Can we update you via Text/SMS? (Reduces the average service time by 10%)

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from Quantum Marine. Message frequency varies. Message & data rates may apply. Text HELP to (778) 909-7077 for assistance. You can reply STOP to unsubscribe at any time.

Please Read Our Disclaimer Below:

Disclaimer *

* By checking this box, I understand that I am bound by all the terms and conditions printed on this work order contract. I further understand that Quantum Coastal Marine is not responsible for any theft or damage, of boat and contents, during storage or transportation, or due to wild animals. Quantum Coastal Marine will not be held responsible for damage to motor or boat while removing rusted or seized parts. I understand that if I do not pay and remove my boat within one day of work completion, that I will be subject to a $20/day storage fee, unless other arrangements have been made. By checking this box I confirm that I have read, accepted and authorized Quantum Coastal Marine to perform repairs and maintenance indicated on the work order.

Select Today's Date *

Customer Signature *

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