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Request a FREE Boat, Watercraft & Jetski Insurance Quote
PERSONAL DATA:
*Your Name:
*Street Address:
Street Address (2):
*City:
*State:
*Zip:
*Email:
*Verify Email:
*Phone:
Fax:
Marital Status:
Home Owner:
Boat Currently Insured?
(If yes, list carrier, and # of years)
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 Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Years of 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 Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Years of 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: $15/30 BI / 10 PD $25/50 BI / 15 PD
$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, autos, etc. here)
If More than 2 Vehicles or Drivers, list Additional Vehicles Year, Makes, and Models, and Driver's Ages and Driving records here:
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