Request a FREE Boat, Watercraft & Jetski Insurance Quote
Please complete this form so that we are better able to answer your questions. Required fields are indicated with an asterisk ( * ).
PERSONAL DATA:
*Your Name:
*Street Address:
Street Address (2):
*City:
*State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*Zip:
*Email:
*Verify Email:
*Phone:
(ie: 5555555555)
Fax:
(ie: 5555555555)
Marital Status:
-- Select --
Single
Married
Divorced
Widowed
Home Owner:
-- Select --
Yes
No
Boat Currently Insured?
-- Select --
Yes
No
(If yes, list carrier, and # of years)
Is this Boat Co-owned?
-- Select --
Yes
No
(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:
Select #
0
1
2
3
4
5 or more
Number & Type of MINOR Cites last 3 years:
Select #
0
1
2
3
4
5 or more
Number & Type of MAJOR Cites last 3 years:
Select #
0
1
2
3
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:
Select #
0
1
2
3
4
5 or more
Number & Type of MINOR Cites last 3 years:
Select #
0
1
2
3
4
5 or more
Number & Type of MAJOR Cites last 3 years:
Select #
0
1
2
3
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:
*Send my quotation via:
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E-Mail
Fax
Regular Mail
Call my by phone!
