Your information will be used for insurance quoting purposes only.


Contact Information

First and Last Name

Email address

Mailing Street Address

City

State

Zip

Phone

Is your residence and mailing address different: ---YesNo

Watercraft is stored at: ---Resident addressMarinaStorage FacilityPublic Parking LotOther Address

Resident address is a: ---HouseTownhomeCondoApartment

Watercraft location address:

Watercraft Operators

#1 Watercraft Operator

First and Last Name:

Marital Status:

Date of Birth:

Any Watercraft or vehicle violations or claims within the last 3 years:
(Please include that date and describe the incident)

Completed water safety course: YesNo

Years of experience operating watercraft:

#2 Watercraft Operator (if not applicable, skip to the Watercraft Hull section)

First and Last Name:

Marital Status:

Date of Birth:

Any Watercraft or vehicle violations or claims within the last 3 years:
(Please include that date and describe the incident)

Completed water safety course: YesNo

Years of experience operating watercraft:

#3 Watercraft Operator (if not applicable, skip to the Watercraft Hull section)

First and Last Name:

Marital Status:

Date of Birth:

Any Watercraft or vehicle violations or claims within the last 3 years:
(Please include that date and describe the incident)

Completed water safety course: YesNo

Years of experience operating watercraft:

Watercraft Hull

Watercraft’s Hull
Description of boat without the engine or trailer

Year:

Make:

Model:

Purchase Date:

Construction: ---FiberglassInflatableMetalWoodPlastic

How long is the watercraft (feet):

Watercraft Style: ---Bass BoatCruiserJet BoatPersonal Watercraft (example: Ski doo, jet ski, etc.)PontoonRunaboutSailboatOtherNot sure

Value of watercraft Hull (without Engine and Trailer) in $:

Watercraft’s Engine or Motor
Main Engine

Propulsion: ---InboardOutboardWater JetInboard/Outdrive

Year: (if known)

Make: (if known)

Model: (if known)

Maximum speed:

Total Horsepower:

Estimated Motor only Value ($):

Diesel Engine: YesNo

2nd Engine (if applicable)

Propulsion: ---InboardOutboardWater JetInboard/Outdrive

Year: (if known)

Make: (if known)

Model: (if known)

Maximum speed:

Total Horsepower:

Trailer
Skip this section if you do not want coverage on the trailer

Trailer Year: (if known)

Trailer Make: (if known)

Trailer Model: (if known)

Trailer only value ($):

Trailer Physical Damage Deductible: ---No coverage$50$100$250$500

Coverages

Liability: ---No coverage$100,000$200,000$300,000$500,000$1,000,000

Medical Payments: ---None$500$1000$2000$5000$10,000

Uninsured/Underinsured Watercraft Bodily Injury: ---No coverage$100,000$200,000$300,000$500,000

Watercraft Deductible: ---No coverage, liability only$50$100$250$500$1000$2000$3000

Emergency Assistance Package: ---None$500$1000

Roadside Assistance for Watercraft Trailer: ---No trailer coverage$300

Thank You!

Please let us know who to thank for the referral