Form

Boat Quote Submission Form

*Marks Required Fields

Insured Name:

Social Security Number:

Occupation:

Date of Birth:

Address: City: State: Zip:

Hull Information:

Year: Make: Model:

Hull ID, if available: Length:

Material:

Fiberglass Steel Wood Aluminum

Watercraft Type: (select one)

Bass Boat

PowerBoat

Sailboat

House Boat

Jet Boat

Pontoon/Deck

Ski Boat

Yacht

Motor:

Year: Make: Model:

Horsepower: Maximum Speed:

Engine Type (select one)

Outboard

Inboard/Outboard

Inboard

Fuel (check those applicable)

Gas Diesel Electric

Mooring/Storage Location

Address: City: State: Zip:

Navigated Waters:

Value

Hull Value:

Motor Value:

Trailer Value:

Liability:

Uninsured Boat Owner:

Med Pay:

Deductible:

Personal Effects:

Towing:

List all tickets and accidents incurred in the last 5 years by any operator that will be listed on the application.

Are there any tickets or violations? Yes No

If yes, list name, date and details below:

List all boating accidents/claims incurred in the last 5 years by any operator that will be listed on the application..

Are there any accidents or claims? Yes No

If yes, list name, date and details below:

Is there a certificate of completion for any boating safety course?

Yes No

List any applicable boat protective devices

Agency Information

Agency Name:
Agency Phone:
Agency Fax:
Agency Email:

Would you like to recieve your Quote by fax or email?
Fax Email

This is only a quote. The risk is subject to the underwriting approval of the application. For coverage to begin as requested, the application must be fully completed, signed and postmarked within 72 hours of the requested effective date, otherwise coverage is bound 12:01 a.m. the day following postmark.

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