Boat Owners Quote Form


GENERAL INFORMATION
Named Insured:
Mailing Address:
City:
State:	Illinois
Zip/Postal:
Social Security #:
Drivers License #:
E-Mail
Phone:
Fax
Marital Status	Married Single

BOAT INFORMATION

Age of Insured Person:		# of years of boat ownership:
Registered State:		Mooring State:
Mooring Zip Code:
Year of Boat:		Make and Model:
Power Type: I/O Inboard Outboard Sail Jetoutboard Jet No Engine
Length:	ft.	Number of Engines:
Horsepower per engine:		Hull Material:
Top Speed:
CURRENT MARKET VALUE OF:
Motor:	$
Hull:	$
Trolling Motor :	$
Trailer :	$
Any Protection Devices (Describe):
BOAT DEDUCTIBLE INFORMATION:

Deductible:	$100 $250 $500 $1000
Towing:	Yes No
Medical Coverage	$500 $1000 $2000 $5000
Uninsured Watercraft Liability:	Yes No
Number of Additional Owners
Any accident marine or other motorized vehicle last 3 years? If yes, please explain below:	Yes No
Minor violations (Boat or Auto)? If yes, please expain.	Yes No
Major violations (Boat or Auto)? If yes, please expain.	Yes No
Have you taken the boater safety course?	Yes No
Have you had boat insurance the last 12 months?	Yes No

NOTICE: Some companies use an insurance score. This can often improve your rate. If you would like us to use this underwriting tool please provide us your social security number above in the dedicated box or in the remarks box below.

(Rules of the Fair Reporting Credit Act and Federal Consumer Credit Protection Law, will apply)

ADDITIONAL INFORMATION
Please use this section to explain any violations, accidents or claims/losses.