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Boat and Personal Watercraft Insurance
This insurance is designed to offer both Liability Protection for you, along with Physical Damage Coverage for your personal watercraft.
Name
*
Prefix
First
Last
Suffix
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Please select
Male
Female
Home Phone
*
###
-
###
-
####
Work Phone
###
-
###
-
####
Email
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
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
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Boat Information
Year
*
Make
*
Model
*
Propulsion Type?
*
Please select
Outboard
Inboard/Outboard
Inboard
Jet
Number of Motors?
*
Total Horsepower?
*
Hull Material?
*
Please select
Fiberglass
Aluminum
Inflatable
Does the boat have an exposed engine?
*
Please select
Yes
No
Is this engine modified for enhanced performance?
*
Please select
Yes
No
What is the maximum speed?
*
Would you like to insure your trailer?
*
Please select
Yes
No
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?
*
Please select
Yes
No
What is the storing/mooring ZIP Code?
*
Is the Watercraft kept
at your residence during boating season?
*
Please select
Yes
No
If yes, where at?
*
Please select
Garage
Driveway
Yard
In-water
Lift
Parking Lot
Other
Is your boat used for
pleasure use only?
*
Please select
Yes
No
Is this a multi-owner watercraft?
*
Please select
Yes
No
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?
*
Please select
Yes
No
If yes, please provide name and address
*
Driver #1 Information
Driver #1 Name
*
First
Last
Driver #1 Birthdate
*
MM
/
DD
/
YYYY
Driver #1 Gender
*
Please select
Male
Female
Drive #1 SSN#
Driver #1 Marital Status
*
Please select
Married
Not Married
Is Current Driver's License valid?
*
Please select
Yes
No
If not, why and what is current status?
Driver #1 License #?
*
Driver #1 Approved Safety Course Completion?
*
Please select
Yes
No
Driver #2 Information
Driver #2 Name
First
Last
Driver #2 Birthdate
MM
/
DD
/
YYYY
Driver #2 Gender
Please select
Male
Female
Drive #2 SSN#
Is Current Driver's License valid?
Please select
Yes
No
Driver #2 Marital Status
Please select
Married
Not Married
If not, why and what is current status?
Driver #2 License #?
Driver #2 Approved Safety Course Completion?
Please select
Yes
No
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?
*
Please select
Yes
No
If yes, please provide prior insurance information including carrier and prior/current term expiration
Are you a member of any boating related organizations?
*
Please select
Yes
No
Primary Resident Status?
*
Please select
Own Home
Own Mobile Home
Rent
Live With parents
Other
Coverage Selections
BI-PD Options:
*
Please select
15/30/10
25/50/10
50/100/25
100/300/50
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?
*
Please select
Yes
No
Third option
Underinsured Motorist
Coverage?
*
Please select
Yes
No
Physical Damage?
*
Actual Cash Value
Total Loss Coverage
Liability Only
Comprehensive Deductible?
*
Please select
1000
500
250
100
None
Collision Deductible?
*
Please select
1000
500
250
100
None
Personal Effects Coverage?
*
Please select
Yes
No
On-Water towing?
*
Please select
Yes
No
Disappearing Deductible?
*
Please select
Yes
No
Roadside Coverage?
*
Please select
Yes
No
Fishing Equipment Coverage?
*
Please select
Yes
No
Transport Trailer Coverage Amount Desired?
*
Referring Agent?
Please select
Michael Pardee
Joel Doty