Watercraft Quote

*Fields marked in red are required*

Personal Information:

First Name		Last Name
Street Address
City		State
Zip
Primary Phone
Secondary Phone
Social Security #
E-mail
Do you currently have Watercraft Insurance	--Please Select-- Yes No
	If yes, how long have you had continuous coverage?	Years	Months
	Present insurance company
	Policy Number:
	When does your policy expire?		ex: 09/30/2005
If no, why?	--Please Select-- Cancelled Non-Renewed Other
	If Other, why?

Driver Information:

Driver 1		Driver 2
First Name		First Name
Last Name		Last Name
Date of Birth		Date of Birth
Sex	Male Female	Sex	Male Female
Date Licensed		Date Licensed
License Number		License Number
License State		License State

Driver 3		Driver 4
First Name		First Name
Last Name		Last Name
Date of Birth		Date of Birth
Sex	Male Female	Sex	Male Female
Date Licensed		Date Licensed
License Number		License Number
License State		License State

Do any drivers have any auto or marine accidents/violations in the last 5 years?	--Please Select-- Yes No
Please list the Driver # Accident/Violation Type Date Description of Incident If Accident	--Please Select-- Not at Fault At Fault

Watercraft Information:

SECTION A (Waverunner Only)

How many seats does the waverunner have?	--Please Select-- 1 Upright 1 Seated 2 Seated 3 Seated 4 Seated
Model Year
Manufacturer
Model
CC Size
Serial Number
Current Value

SECTION B (Boat Only)

Model Year
Manufacturer
Model
Vessel Length	Feet Inches
Motor Type	--Please Select-- Inboard/Outboard Outboard Sailboat Inboard Jet Outboatd Jet Drive No Engine (Not Sailboat)
Number of Engines
Horsepower per engine
Hull Material	--Please Select-- Fiberglass Aluminum Fiberglass Over Wood Wood Steel Composite Other If other, please specify

SECTION C (Waverunner and Boat)

Where will the watercraft be primarily used?	--Please Select-- Inland Waters Coastal Waters
Type of Use	--Please Select-- Personal/Recreational Commercial
Where will the watercraft be kept?	--Please Select-- Garage Marina

Coverage Limits

Personal Watercraft Deductible	--Please Select-- 250 500 1000
Bodily Injury	--Please Select-- 15/30 20/40 30/60 50/100 100/300 250/500
Property Damage	--Please Select-- 5 10 15 20 25 30 50 100 250
Uninsured Boat Owners Liability	--Please Select-- None 15/30 20/40 25/50 30/60 50/100 100/300 250/500
Watersports Liability, Bodily Injury	--Please Select-- None 15/30 20/40 25/50 30/60 50/100 100/300 250/500	*Recommended if you plan on participating in waterports
Watersports Liability, Property Damage	--Please Select-- 5 10 15 20 25 30 50 100 250	*Recommended if you plan on participating in waterports