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Zip Code
Driver's License Number
Tickets or accidents in the last three years (auto)
If so, approximate dates
Do you own a home?
Daytime Phone Number
E-mail Address
Date of Birth
Male or Female
Are you married or single?
Watercraft
Year
Make
Model
Hull Material
< Choose One >
Fiberglass
Aluminum
Inflatable
Number of Motors
Total Horsepower
Propulsion Type
< Choose One >
Outboard
Inboard/Outboard
Inboard
Is the vessel modified for enhanced performance?
Yes
No
If so, what is the max speed?
Rating Amount
< Choose One >
Total Loss Replacement (Purchase Price)
Agreed Value (Current Market Value)
Actual Cash Value
Storage Zip Code
Watercraft Use
< Choose One >
Pleasure Use
Racing Speed (Sailboats Only)
Are there multiowners?
Yes
No
Coverages
Physical Damage
Agreed Value
Actual Cash Value
None - Liability Only
Comp Deductible
$250
$500
$1000
$2500
$5000
Collision Deductible
$250
$500
$1000
$2500
$5000
Liability - Bodily injured of others and property damage of others (B.I. per person/ B.I. per accident/ Property damage of others)
< Choose One >
$10,000/$20,000/$10,000
$25/$50/$10
$50/$100/$25
$50/$100/$50
$100/$300/$50
$100/$300/$50
$250/$500/$100
$100,000 Combined Single Limit
$300,000 Combined Single Limit
$500,000 Combined Single Limit
Uninsured Boaters
< Choose One >
None
10/20
Medicalpayments per person (on insured boats)
< Choose One >
None
$1,000 per person
$2,500 per person
$5,000 per person
$7,500 per person
$10,000 per person
Personal Property (limits - minimum $1,000 - maximum $5,000)
On water towing
< Choose One >
None
$300
$500
$1,000
$2,500
Fishng Equipment ($250 deductible)
< Choose One >
None
$1,000
$2,500
$5,000
$10,000
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