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:
Drivers License #
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:
$100/300 BI / 50 PD
$250/500 BI / 100 PD $500,000 CSL
$1 000,000 CSL
Hull Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Uninsured Boaters Coverage?
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 Provide a Proposal!
Click Button Below When Done
Please Click Only Once . . . May take up to 30 seconds!
