NAMEEMAIL ADDRESS

ADDRESS

ZIP CODE

COUNTY

                                      YEAR             MAKE/MODEL            VALUE 

BOAT                      

MOTOR                  

TRAILER                

TYPE OF MOTOR In Board Out Board Sail Other

LENGTH                     

HORSEPOWER        

MAXIMUM SPEED       

TYPE OF BOAT  Bass Ski Runabout Deck Personal Watercraft Other     

IS OPERATOR'S MVR CLEAR?  Yes No

ANY OPERATORS UNDER 21?  Yes No

*PLEASE LIST NAMES AND AGES OF ALL OPERATORS IN REMARKS SECTION.

WHERE IS THE BOAT STORED?

WHAT DEDUCTIBLE? 

COVERAGES:

    BI 20/40 25/50 50/100 100/300 250/500 100 CSL 300 CSL 500 CSL         PD 10,000 25,000 50,000 100,000 500,000     

    MED PAY 1000 2000 5000 10,000

    COMPREHENSIVE No Coverage 50 100 250 500 1000

    COLLISION  No Coverage 50 100 250 500 1000

    UNINSURED BOATERS  REJECTED 20/40 25/50 50/100 100/300 250/500 100 CSL 300 CSL 500 CSL

    TOWING  Yes No

    SKIERS LIABILITY  Yes No

ANY OTHER INFORMATION PERTINENT TO YOUR QUOTE!

REMARKS: (DON'T FORGET TO LIST ALL OPERATORS)

I prefer to be contacted by: Email Phone Fax Regular Mail

Thank you for filling out the above quote application.  We will get back to you ASAP!!!