| GENERAL INFORMATION: |
| *Name: |
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| *Address: |
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| *City: |
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| *State: |
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| *Zip Code: |
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*Garaging Address:
(If different from mailing address)
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| *E-mail address: |
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| *Daytime Phone Number: |
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| *Current Insurance Carrier: |
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| *Exp. Date of Current Insurance: |
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DRIVER INFORMATION - Please list ALL persons of driving age in your household below: |
| Driver 1: |
*Name: |
|
| |
*Sex: |
Male
Female |
| *Marital Status: |
Single
Married
|
| *Date of Birth: |
Mo.
Day
Year
|
| *Date First Licensed: |
Mo.
Year |
| *Social Security Number: |
|
| |
|
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| Driver 2: |
Name: |
|
| |
Sex: |
Male
Female |
| Marital Status: |
Single
Married |
| Date of Birth: |
Mo.
Day
Year
|
| Date First Licensed: |
Mo.
Year |
| Social Security Number: |
|
| |
|
| Driver 3: |
Name: |
|
| |
Sex: |
Male
Female |
| Marital Status: |
Single
Married |
| Date of Birth: |
Mo.
Day
Year
|
| Date First Licensed: |
Mo.
Year |
| Social Security Number: |
|
| |
|
| Driver 4: |
Name: |
|
| |
Sex: |
Male
Female |
| Marital Status: |
Single
Married |
| Date of Birth: |
Mo.
Day
Year
|
| Date First Licensed: |
Mo.
Year |
| Social Security Number: |
|
| BOAT INFORMATION : |
| *Make: |
|
*Model: |
|
| *Year: |
|
*Hull Material: |
|
| *Type of Propulsion: |
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*Cost When New: |
|
| *Number of Motors: |
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*Total Horsepower: |
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| *Maximum MPH: |
|
|
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| *Years of Boating Experience: |
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*Does this cost
include trailer?
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Yes
No |
DRIVING RECORD -
List any and all accidents, claims, or comprehensive losses (glass, at fault, not at fault, hit and run),
tickets and suspensions
in the past 5 years: |
| Driver's Name: |
|
Date of Incident: |
Mo.
Year |
| Describe Incident: |
|
| |
|
| Driver's Name: |
|
Date of Incident: |
Mo.
Year |
| Describe Incident: |
|
| |
|
| Driver's Name: |
|
Date of Incident: |
Mo.
Year |
| Describe Incident: |
|
| |
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| COVERAGES -
Please select the coverages you would like on your quote: |
| *Liability: |
$100,000
$250,000
$500,000 |
| *Medical Expense: |
$
1,000
$2,000
$5,000
$10,000 |
| *Uninsured Boaters: |
$10,000
$100,000
$250,000
$500,000 |
|
In order to give you the most accurate quote, we will need to run a few reports. The first is a Motor Vehicle Report. The second is a Clue Report which shows prior claims. The third is an Insurance Score, which will contain credit information. In order to run these reports and obtain a quote for you we need your permission. By submitting this request for a quote you are giving us permission to obtain these reports.
Any information which we have or may obtain about you or other individuals listed as policyholders on your policy will be treated confidentially. You have the right to see personal information collected about you and you have the right to correct any information which may be wrong. Upon your request the address of the reporting agency will be supplied so that you can request this information.
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REMEMBER!
Completion of this form constitutes a request for a quotation.
It is not intended to replace or act as an actual insurance contract or binder. |
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