EmailMe Form - Boat and Personal Watercraft Insurance

Name *

Prefix First Last Suffix

Date of Birth *

MM / DD / YYYY

Gender *

Home Phone *

### - ### - ####

Work Phone

### - ### - ####

Email

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Have you moved in the last 60 days? If yes, please give previous address.

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Boat Information

Year *

Make *

Model *

Propulsion Type? *

Number of Motors? *

Total Horsepower? *

Hull Material? *

Does the boat have an exposed engine? *

Is this engine modified for enhanced performance? *

What is the maximum speed? *

Would you like to insure your trailer? *

What is the total market value of Watercraft including trailer value and permanent equipment on craft? *

$ Dollars . Cents

What year did you purchase this Watercraft? *

Are you the original owner? *

What is the storing/mooring ZIP Code? *

Is the Watercraft kept
at your residence during boating season? *

If yes, where at? *

Is your boat used for
pleasure use only? *

Is this a multi-owner watercraft? *

Hull ID Number? *

Registration Number? *

What is the Year, Motor Make, and Horsepower of your Outboard Engine? *

What is the Year and Make of your Trailer? *

Is there a lienholder or additional interest on this watercraft? *

If yes, please provide name and address *

Driver #1 Information

Driver #1 Name *

First Last

Driver #1 Birthdate *

MM / DD / YYYY

Driver #1 Gender *

Drive #1 SSN#

Driver #1 Marital Status *

Is Current Driver's License valid? *

If not, why and what is current status?

Driver #1 License #? *

Driver #1 Approved Safety Course Completion? *

Driver #2 Information

Driver #2 Name

First Last

Driver #2 Birthdate

MM / DD / YYYY

Driver #2 Gender

Drive #2 SSN#

Is Current Driver's License valid?

Driver #2 Marital Status

If not, why and what is current status?

Driver #2 License #?

Driver #2 Approved Safety Course Completion?

Driver #2 Years of Riding Experience?

Driving History

Please list all violations, at-fault and not at-fault accidents in the last 35 months and the dates for each. *

Misc Information

Has the named insured had continuous boat liability insurance for the last 12 months? *

If yes, please provide prior insurance information including carrier and prior/current term expiration

Are you a member of any boating related organizations? *

Primary Resident Status? *

Coverage Selections

BI-PD Options: *

Bodily injury (BI) and Property Damage are both types of liability coverages that thus cover those that you may cause damage to in an acciden

Uninsured Motorist
Coverage? *

Underinsured Motorist
Coverage? *

Physical Damage? *

Comprehensive Deductible? *

Collision Deductible? *

Personal Effects Coverage? *

On-Water towing? *

Disappearing Deductible? *

Roadside Coverage? *

Fishing Equipment Coverage? *

Transport Trailer Coverage Amount Desired? *

Referring Agent?