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Watercraft Quote
General Information
First Name:
Last Name:
Address:
City:
State:;	Zip:
Telephone:	- -
EMail:
Current Coverage Information
Have you had continuous watercraft coverage in the last year? Yes No
Watercraft Operators in the Household
Driver Name	DOB	M/F	Driving Experience	Occupation
Single Male Single Female Married Male Married Female Less than 1 Year 1 to 2 Years 3 to 5 Years 6 to 10 Years 10+ Years
Single Male Single Female Married Male Married Female Less than 1 Year 1 to 2 Years 3 to 5 Years 6 to 10 Years 10+ Years
Single Male Single Female Married Male Married Female Less than 1 Year 1 to 2 Years 3 to 5 Years 6 to 10 Years 10+ Years
Single Male Single Female Married Male Married Female Less than 1 Year 1 to 2 Years 3 to 5 Years 6 to 10 Years 10+ Years
Have any drivers completed a Certified Safety Boating Course?
Operator 1 Operator 2 Operator 3 Operator 4
Accidents and Violations
Does Operator 1 one have any of the following?
Moving Violation Not at Fault Accidents At Fault Accidents
Does Operator 2 one have any of the following?
Moving Violation Not at Fault Accidents At Fault Accidents
Does Operator 3 one have any of the following?
Moving Violation Not at Fault Accidents At Fault Accidents
Does Operator 4 one have any of the following?
Moving Violation Not at Fault Accidents At Fault Accidents
Accident/Violation Details
Watercraft Descriptions
Type of Watercraft Select Below Sailboat Houseboat Pontoon Boat Bass/Fishing Outboard Inboard or I/O Jetski    Modified for Performance Select Below No Yes
Year    Mfr. Model Name
Model Number   Length
Purchase Date Purchase Price
Docking Location   Winter Lay-up
Waters Navigated Select Below Inland Coastal Maine Maine to Florida
Total Value Of Unattached Watercraft Accessories: $
Motor Description
Type of Motor: Select Below None Inboard Inboard/Outdrive Outboard
Number of Motors: hp Each: Max M.P.H.:
Purchase Date: Purchase Price: $
Trailer Description
Year: Manufacturer: Model:
Purchase Date: Purchase Price:
Watercraft Liability Coverage Information
Bodily Injury and Property Damage limits of liability: Select Below $20,000/ $40,000 / $10,000 $25,000 / $50,000 / $25,000 $50,000 / $100,000 / $25,000 $100,000/ $300,000 / $50,000 $250,000 / $500,000 /$100,000 $100,000 Combined Single Limit $300,000Combined Single Limit $500,000 Combined Single Limit
Medical Payments Coverage None $5,000 $10,000 $20,000
Uninsured Boaters Coverage Limits (optional): SelectBelow< $20,000 / $40,000 $25,000/ $50,000 $50,000 / $100,000 $100,000/ $300,000 $250,000 / $500,000 $100,000Combined Single Limit $300,000 Combined Single Limit $500,000 Combined Single Limit
Physical Damage Coverage
Physical Damage Deductible: N/A $100 $250 $500 $1000
Remarks
Any changes or additions will not take effect until confirmed by your agent. Coverage has not been bound by this submittal.