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!
Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.
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