Watercraft Quote

Agency Information

Agency Name *

Agency Code *

Email *

Agent First Name *

Agent Last Name *

Phone *

Applicant Information

Insured - First Name & Last Name *

DOB *

SSN

Gender *

Male

Female

Current Mailing Address *

Country

City

State

Zip code

Has applicant moved in last 6 months? *

Yes

Prior Mailing Address

Country

City

State

Zip code

Is the mailing address the same as the location address? *

Yes

Location Address *

Country

City

State

Zip code

License Status *

Primary Phone number *

**If any of the following apply, customer is not eligible for coverage: Requires an SR-22 financial responsibility filing, any vehicle held for sale or consignment, operator convicted of a felony, applicant or operator had license suspended, canceled, revoked or barred within the last 3 years, customer is not the titled owner of the unit(s) or if any unit has unrepaired or existing damage.

Requested Effective Date *

Unit type *

Discounts & Surcharges (check all that apply) *

More than 1 American Modern policy with Graham-Rogers

Applicant will be paying in full

Applicant enroll in paperless policy delivery

Applicant owns primary residence

American Modern Policy Number: *

Has the applicant had continuous insurance or a lapse of less than or equal to 31 days? *

Yes

Number of days uninsured *

Has the applicant had any watercraft losses/accidents in the last 5 years? *

Yes

Watercraft accidents/violations: *

At fault

Not at fault

Minor violation

Major violation

Has the applicant had any auto losses/accidents in the last 5 years? *

Yes

Auto accidents/violations: *

At fault

Not at fault

Minor violation

Major violation

Operator Information: List all licensed household members & regular use operators

Operator 1 (Named Insured)

Drivers

First Name *

Last Name *

Date of Brith *

Gender *

Male

Female

Spouse is required to be listed as operator and may be excluded if requested.

Is the driver a member of any of the following associations? If so, select one. *

Has the applicant completed safety course? *

Yes

Date completed *

Does this driver have ownership interest in the vessel *

Yes

Describe: Include date, amount & fault: *

Any other operators? *

Yes

First Name *

Last Name *

Gender *

Male

Female

Date of Brith *

Relationship to insured *

Spouse

Child

Other - Specify:

SSN

Driver 2 Accidents or violations in the last 5 years? *

Yes

Driver 2 Describe: Include date, amount & fault: *

Unit Information

Is this a new purchase? *

Yes

Current Carrier *

Expiration date *

Hull ID *

Year *

Make *

Length (feet) *

Model *

Total Horsepower *

Hull Construction *

Fuel Type *

Number of Engines *

Purchase date *

Purchase Price *

Value *

Is the unit have any modifications? *

Yes

Explain modifications:

Weight *

Is the Storage address different than the location address? *

Yes

Storage Address *

Country

City

State

Zip code

Storage Construction *

Frame

Masonry

Other

Describe Other: *

Vehicle Recovery/Tracking System? *

Yes

Add Engine Details? *

Yes

Year *

Make *

Model *

Horsepower *

Serial Number *

Add Trailer? *

Yes

VIN/Serial Number *

Year *

Make *

Length (feet) *

Model *

Value *

Coverages

Eligible Motorcycles 2 years or newer will be quoted with Replacement Cost or ACV Upon request. ATV/UTV/Golf Carts are not eligible for RCV.

Liability limits *

Medical Payments *

Hull Deductible *

Hull Settlement Option *

Agreed Value

Actual Cash Value

Haul Out *

Personal Effects *

Towing and Emergency Expense *

Charted Fishing Guide: Number of Days: *

Charted Fishing Guide: Number of Passengers: *

Charted Fishing Guide: Use: *

Boat Lift *

Extended Parts Replacement *

Rental Reimbursement *

Port Risk *

Trailer Physical Damage Limit

Trailer Settlement Option *

Agreed Value

Actual Cash Value

Any Additional Questions or Comments? If there is more than 1 Unit, please provide responses for all of the Unit Information questions for each additional unit in this box.

reCAPTCHA is required.