On-Line
Boat & Jet Ski
Insurance Quote Form
One Simple Form - takes
only 2-3
Minutes! Your
Personal Data
Your
Name:
Street
Address:
City:
Select
State:
Zip
Code:
E-Mail
(REQUIRED):
E-Mail
again for accuracy:
Phone:
Fax
(optional):
Marital
Status:
Single
Married
Homeowner?
Yes No
Boat
Currently Insured?
(If yes, list carrier,
and # of years continuous. If none, type
N/C)
Is this Boat
Co-owned?
(If yes, list all owners
names)
OPERATOR INFORMATION
#1
Name:
Birthdate:
Sex
(M/F):
# Years
U.S.
Licensing:
Be specific to tell if accidents
are "at-fault" or "NOT-at-fault" -
(carriers require proof on NOT-at-fault
accidents); Also, be specific as to TYPE
of violations, and approximate DATES of
each in the fields
below:
Number &
Type of Accidents last 3
years:
Number &
Type of MINOR violations last 3
years:
Number &
Type of MAJOR violations last 3
years:
Number of
Years
Boating Experience:
OPERATOR INFORMATION #2
(if none, leave
blank)
Name:
Birthdate:
Sex:
# Years
U.S.
Licensing:
Be specific to tell if accidents
are "at-fault" or "NOT-at-fault" -
(carriers require proof on NOT-at-fault
accidents); Also, be specific as to TYPE
of violations in fields
below:
Number &
Type of Accidents last 3
years:
Number &
Type of MINOR violations last 3
years:
Number &
Type of MAJOR violations last 3
years:
Number of
Years
Boating Experience:
VESSEL & UNDERWRITING
INFORMATION
Year of
Boat:
Make &
Model
(be specific):
Boat
Length:
Hull Type
(wood, Metal,
fiberglass, etc):
Max. Speed
(in MPH):
Market Value:
$
Engine
Make:
Engine Type:
(Inboard, I/O,
Jet)
Engine Horse
Power:
Fuel Type:
(Gas, Diesel,
etc.)
Trailer Cov.
Needed?
Yes
No
Yr./Make/Model
of
Trailer:
Trailer Value:
$
Where is
boat
moored or stored?
Describe
waters
boat taken on?
Describe
boat
general usage?
(fishing, ski, etc.)
VESSEL
COVERAGES:
Limits of
Liability:
$50/100 BI / 25
PD $100/300
BI / 50 PD
$250/500 BI / 100
PD
Hull
Coverage:
NO
Coverage $250
Deductible
$500 Deductible
$1000
Deductible
Water Ski
Medical Coverage?
Yes
No
Uninsured
Motorists Cov.?
Yes
No
Comments or
Remarks:
(List additional
drivers,
special coverages, etc.
here)
Send my
quotation via:
E-Mail Fax
Regular Mail
Call me by
Phone!
Thank you for filling out
this form
COMPLETELY!
We value your input as PRIVATE
information. Every step has been taken
to insure your privacy, security, and
our intent is to release quote
information only to you. We will not
give your data to ANY other person or
group for sales, marketing, or ANY
other purposes. By checking the box
below you agree to allow our agency to
release this information via the method
you have chosen, and to release us from
any liability should this information
be accidentally viewed by others. Our
intention is to maintain your complete
privacy.
Yes, I Agree. Please Send
Me a Boat Quote
NOW!
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