On-Line Boat & Jet Ski
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name:
Street Address:
City:
State: (Must be Florida)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
Primary Insured's Occupation:
Marital Status:
Single Married
Homeowner?
Yes No
Boat Currently Insured?
(If yes, list carrier, and # of years continuous. If none, type N/C)
Is this Boat Co-owned?
(If yes, list all owners names)
OPERATOR INFORMATION #1
Name:
Birthdate:
Sex (M/F):
# Years U.S.
Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Number of Years
Boating Experience:
OPERATOR INFORMATION #2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S.
Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Number of Years
Boating Experience:
VESSEL & UNDERWRITING INFORMATION
Year of Boat:
Make & Model
(be specific):
Boat Length:
Hull Type
(wood, Metal,
fiberglass, etc):
Max. Speed
(in MPH):
Market Value: $
Engine Make:
Engine Type:
(Inboard, I/O, Jet)
Engine Horse
Power:
Fuel Type:
(Gas, Diesel, etc.)
Trailer Cov.
Needed?
Yes No
Yr./Make/Model
of Trailer:
Trailer Value: $
Where is boat
moored or stored?
Describe waters
boat taken on?
Describe boat
general usage?
(fishing, ski, etc.)
VESSEL COVERAGES:
Limits of
Liability:
$15/30 BI / 10 PD $25/50 BI / 15 PD
$50/100 BI / 25 PD $100/300 BI / 50 PD
$250/500 BI / 100 PD
Hull Coverage:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
Water Ski
Medical Coverage?
Yes No
Uninsured
Motorists Cov.?
Yes No
Comments or Remarks:
(List additional drivers,
special coverages, etc. here)
Send my quotation via:
E-Mail Fax
Regular Mail
Call me by Phone!
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