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Boat and Personal Watercraft Quote Questionaire

Please complete the form below and submit through our Secure Server
Customer Information
First Name  
Middle Name  
Last Name  
Sex:   M
Marital Status   Married
Home Address  
City   State Zip
Date of Birth (MM/DD/YYYY)  
Social Security Number  
Phone Number  
Your Email Address *  
Automobile Driver's License Status  
Primary Residence   Own Home/Condo
    if other, specify
Other Operator Information
(any operator in or outside the household with regular access to insured vehicle more than 12 times per year)
    Name   Date of Birth   Marital Status
1       Married
2       Married
3       Married
4       Married
Driving Record
Please list Accidents and Moving Violations in the last 5 years for all drivers
  Date   Description   Auto or Boating?
Boat Information
Type (i.e. pleasure, fishing, sail, etc.)  
Number of Engines  
Total Horsepower  
Propulsion Type   Inboard     Outboard
Inboard/Outbaord     Jet
Hull Material  
Enhanced Performance Modifications?
(i.e. blowers, superchargers, etc)
Trailer Coverage  
Rating Base
(include value of trailer and permanent/portable boating equipment if coverage desired)
Underwriting/Discount Information
Dock/Mooring/Storage Zip Code  
Watercraft Use (i.e. pleasure, business, etc.)  
Multi-owner (not in same household)?  
Discounts   Homeowner 5%    Original Owner 10%
Multi-Policy 5%    Safety Course5%
Transfer 5%
Prior Boat Insurance?  
Prior Carrier  
Effective Dates  
Coverage Information
Hull Coverage (Comp & Collision)   Total Loss/Replacement (New Boats only)
Agreed Value    Actual Cash Value
Hull Deductible   $250    $500    $1000    $2500    $5000
Liability Coverage Limits  
Underinsured/Uninsured Boater Coverage  
Medical Payments Coverage   $1000    $2500    $5000    $7500    $10000
Primary Personal Effects Coverage   $1000    $2000    $3000    $4000    $5000
Fishing Equipment Coverage   $1000    $2500    $5000    $10000   
Emergency Towing (on-water)   $300    $500    $1000    $2500   
Coastal Navigation   75 Nautical Miles    $125 Nautical Miles   
Note to Customer: To provide an accurate quote, we have asked you numerous questions about yourself and your vehicle. As part of the quoting process, we will also be utilizing various consumer reports which may include reports regarding your credit history. All information we acquire may be provided to our insurance carriers. Please place your initials here if we have your permission to gather and share information as described herein:

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