Watercraft Quote Request
Please note: We cannot bind coverage from an email request. Coverage is bound after you receive a written email or telephone confirmation from an agency staff member.
Effective Date:
Your Name:
Your Mailing Address:
 Street

City & State                                  Zip
  
E-mail Address:
Daytime Phone #:
Choose One: Please call me with quote premium.
Please send quote via e-mail.
Description of Property:
Motor type:
 Number of Engines:
 Boat Type:
 Other Boat Type
Fuel:
 Maximum Speed:
 Hull Material:
 Other Hull Material:
Insured Watercraft:
Boat:
Year   Manufacturer                  Model

Serial Number                           Length TotalHP
Outboard Motor:
Year         Manufacturer                    Model

Serial Number                                 TotalHP
Trailer:
Year         Manufacturer            Serial Number
Coverages:   Limits:
Boat (Including Auxiliary Equipment, please break down o/b information)
Outboard Motor 1.
(ACV Coverage)
Outboard Motor 2.
(ACV Coverage)
Boat Trailer
Personal Property
($500 Automatic)
Commercial Towing
($400 Automatic)
Boat Liability
(ACV Coverage)
Medical Payments
($1000 Automatic with Liability)
Uninsured Boater
Optional Coverages
 Agreed Value Endorsement
Actual Cash Value
Fishing Equipment - Limit:  
Safety Equipment:
Check all that apply:
GPS
Automatic CO2 (Halon)
Ship to Shore Radio (VHF)
Depth Sounder
Electronic Burglar Alarm 		Radar
Plotter
EPIRB
Vapor Detector Alarm
Operator Information:
Date of Birth:
 Years of Boating Experience:
Waters to be Navigated:
Inland waters of the following states:
 Coastal waters of the following states:
Is the boat chartered or used for other than private pleasure purposes?    Yes     No
Previous Loss Information
Please describe any losses or claims filed on your Boat Insurance in the last 3 years.
Please include the date and type of the loss, as well as the amount of the claim
Additional Comments
Please use the box below to enter any additional information you wish to include:
        

If you have not received a response from us within one business day, please contact us again. Thank you.