Watercraft Quote Form

APPLICANT INFORMATION
First Name:    
Last Name:    
Address:      
City:    
State:    
Zip:    
Phone:    
Email:    
  Married Single                          Own Home Rent Other  
Currently Insured?: Yes No With Who?        Expiration Date:
Is is ok for us to run a motor vehicle report and insurance score? Yes No
Year/Make/ Model:        Inboard Outboard        Gas Diesel         Inland Coastal
Amount of Coverage for Boat:                    Motor:                Trailer:
Length of Boat :                          Horsepower:                        Maximum Speed:
 
Drivers in Household
Name: Date Of Birth: DL#: SS#:
Name: Date Of Birth: DL#: SS#:
Name: Date Of Birth: DL#: SS#:
Name: Date Of Birth: DL#: SS#:
       
Accidents or Violations in the last 5 years for all drivers
Type: Date:    
Type: Date:    
       
Coverage
Bodily Injury/ Property Damage:
25/50/25 50/100/50 100/300/100 250/500/100
 Medical Payments:  1,000 2,000 5,000 none
Personal Effects: 1K 2K 3K 4K 5K UM:   25/50 50/100 100/300 none
Comprehensive: 100 250 500 100 none Collision:   100 250 500 1000 none
Towing: 300 500 1000 2500 none    
Do you want any coverage for Special Equipment (ski, depth finders, life jackets, fishing tackle)? Yes No