Contact and General Information
*First Name
*Last Name
*Street Address
City/St/Zip
Phone Number
Alternate Number
*Email Address
Mailing Address - if different from above
Mailing Address
Operator 1 Information
First Name
Last Name
Gender
Male Female
Birthdate
Marital Status
-Select- Single Married Separated Divorced Widowed Domestic Partner
Years of boating experience
State Licensed
Occupation
Operator 2 Information
First Name
Last Name
Gender
Male Female
Birthdate
Marital Status
-Select- Single Married Separated Divorced Widowed Domestic Partner
Years of boating experience
State Licensed
Occupation
Boat Information
Year
Make
Model
Type
-Select- Sail Boat Ski Boat Pontoon Boat House Boat Cabin Cruiser Bass Fishing Boat Flat Bottom Tunnel Hull Pickle Fork
Identification Serial Number
Cost New Value
Hours Used Each Year
-Select- Under 50 51-100 101-200 201-300 301-400 401-500 500+
Boat Length
Watercraft Weight
Describe any accessories or special equipment including cost when new:
Ownership
-Select- Leased Paid Off Financed
Lienholder (if any)
Street Address:
City:
State:
Zip Code:
Is the boat docked/stored at a Marina?
Yes No
If yes, Marina name
Trailer Information
Year
Make
Model
Type (# of axles)
-Select- single axle double axle three axles
Cost New Value
Identification Serial Number
Motor Information
Year
Make
Model
Type (in/out)
-Select- no motor out-board in-board inboard/outboard
Identification Serial Number
Cost New Value
Horsepower or Motor Size
Number of motors
Deductible Information
Boat
and Motor
Comp (theft)
-Select- None 250 500 1,500 2,000
Collision
-Select- None 250 500 1,500 2,000
Trailer
Comp (theft)
-Select- None 250 500 1,500 2,000
Collision
-Select- None 250 500 1,500 2,000
Violation Information - Last 3 years (minor violations) / Last 5 years (major violations)
Operator 1
Minor Violations - speeding, turn, stop sign, red light, etc.
-Select- None 1 2 3 4
Accidents - non chargeable
-Select- None 1 2 3 4
Accidents - chargeable
-Select- None 1 2 3 4
Major violations - drunk driving, reckless,hit and run, etc.
-Select- None 1 2 3 4
Operator 2
Minor Violations - speeding, turn, stop sign, red light, etc.
-Select- None 1 2 3 4
Accidents - non chargeable
-Select- None 1 2 3 4
Accidents - chargeable
-Select- None 1 2 3 4
Major violations - drunk driving, reckless,hit and run, etc.
-Select- None 1 2 3 4
Coverage Information
Personal Liability / Bodily Injury
-Select- 15,000/30,000 25,000/50,000 30,000/60,000 50,000/100,000 100,000/300,000 250,000/500,000
Personal Liability / Property Damage
-Select- 5,000 10,000 25,000 50,000 100,000
Uninsured Motorist / Bodily Injury
-Select- No Coverage 15,000/30,000 25,000/50,000 30,000/60,000 50,000/100,000 100,000/300,000 250,000/500,000
Uninsured Motorist / Property Damage
-Select- No Coverage 3,500 Deductible Waiver
Medical Payment
-Select- No Coverage 1,000 1,500 2,000 2,500 5,000 10,000 15,000 20,000 25,000 50,000 100,000
Miscellaneous Information
Does the Boat have a Fire System?
Yes No
Is or will the boat be used in connection with any operator's business or profession?
Yes No
What is the Fuel Type?
-Select- n/a gas diesel
What is the estimated annual hourly usage?
In which state is or will the boat be registered in?
Current Insurance Company
Expiration Date
Current Premium
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote
Morning Afternoon Evening Anytime
Or Specify Other: