EmailMeForm
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Name
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Email Address
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Phone #
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Date of Birth
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Occupation
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Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Best Day and Time to Call
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Boat Year (Must be a 2010 or newer to qualify)
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Boat Make/Model
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Boat Purchase Date
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Motor Year
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Motor Make/Model and HP
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Primary operator Drivers License Number
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Marital Status
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Single
Married
Housing Status
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Rent
Own
Other
Boat insurance provider
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Liability Limit
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How Soon Do You Need Coverage
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Years experience operating a watercraft?
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Have there been any boating losses in the last 3 years?
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Yes
No
Any automobile / watercraft violations occurring in the past 3 years?
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Yes
No
Has this driver's license been suspended or revoked in the last 3 years?
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Yes
No
Does any operator have any criminal convictions(Arson/Burglary/DUI) within the past 5 years?
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Yes
No
Has this client's insurance ever been canceled, declined, or non-renewed?
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Yes
No
Will you be guiding from this watercraft
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Yes
No
Have you completed an approved watercraft safety course? (Proof will be required before binding)
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Yes
No
Other quotes to be included
Home/Renters
Auto
RV/Motorhome
Motorcycle/ATV
Firearm Liability Insurance
Agent Preference if Available
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Ben Green
Kevin Sigillito
How Did You Hear About Us?
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Questions or Comments
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