EmailMe Form - Green Kayak

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Ben Green Insurance Agency cannot insure Kayaks on a stand-alone basis.
We will need supporting business such as Home, Renters, Auto, Camper, Business insurance in order to provide a policy.
If you are not interested in this, we will ask that you seek insurance for your kayak elsewhere.

Name *

Email Address *

Phone # *

Date of Birth *

Occupation *

Address *

Street Address City State / Province / Region Postal / Zip Code

Best Day and Time to Call *

Kayak Year *

Kayak Make/Model *

Kayak Purchase Date *

Motor Year *

Motor Make/Model and HP *

Primary operator Drivers License Number *

Marital Status *

Single

Married

Housing Status *

Rent

Own

Other

Kayak insurance provider *

Liability Limit *

How Soon Do You Need Coverage *

Years experience operating a watercraft? *

Estimated Value: (Please describe gear in notes) *

Have there been any boating losses in the last 3 years? *

Yes

No

Any automobile / watercraft violations occurring in the past 3 years? *

Yes

No

Has this driver's license been suspended or revoked in the last 3 years? *

Yes

No

Does any operator have any criminal convictions(Arson/Burglary/DUI) within the past 5 years? *

Yes

No

Has this client's insurance ever been canceled, declined, or non-renewed? *

Yes

No

Will you be guiding from this watercraft *

Yes

No

Other quotes to be included

Agent Preference if Available *

Ben Green

Kevin Sigillito

Questions/Comments/Notes *