Jet Ski Quote Form


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

JET SKI INFORMATION
Number of Jet Skis:
Liability coverage only is available.
Any Jet Ski over 14Ft In Length?:	Yes No	Max Number of Passengers :
Jet Claims or Losses? If yes, please explain below.	Yes No

Any Operator under 14?:	Yes No
Is Jet Ski Rented or Leased?:	Yes No
Use in Racing?:	Yes No
Engine or Pump Altered?:	Yes No
Any Policy Cancelled (Other than nonpay)?:	Yes No

Where and how is the jet ski stored? Explain:

Year:		Model Number:
Make:		VIN:

Engine Displacement Unit (Total Cubic CM):	0-600 601-700 701-850 851-1099 1100+
JET SKI COVERAGE
Jet Ski Value:	$
Trailer Value:	$
Liability Limits:	$20/40 BI / 15 PD $25 / 50 / 25 $50 /100 / 25 $50 / 100 / 50 $100 / 300 / 50 $100 /300 / 100
Medical Coverage	$500 $1000 $2000 $5000
Uninsured Boatowners Liability:	Yes No
Watersport Liability:	Yes No
Number of Owners
Any accident marine or other motorized vehicle? If yes, please explain below:	Yes No
Minor violations? If yes, please expain.	Yes No
Major violations? If yes, please expain.	Yes No
Suspended license	Yes No
Have you had insurance on a jet ski 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.
Provide information on 2nd jet ski and/or any other regular operators.