Customer Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Email Address
*
Social Security Number
*
Marital Status
*
Boat type
Please Select
Pleasure
Fishing
Sail
etc.
Year
*
Make
*
Model
*
Length
*
HIN#
*
Propulsion Type
*
Please Select
Inboard
Outboard
Inboard/Outboard
Jet
Non-Powered
Total Horsepower?
*
Maximum Speed
*
Trailer coverage
Yes
No
Where is the boat stored during boating season?
*
Hull Material
*
Primary Residence Type?
Please Select
Own a home/condo
Own a manufactured home (10 years or newer)
Rent
Live with Parents
Other
Water craft use?
Please Select
Pleasure
Business
Other
Prior boat insurance?
Yes
No
COVERAGE INFORMATION:
Hull Material
Please Select
(Comp & Collision) (Total Loss Replacement (new boats only)
Agreed Value
Actual Cash Value
Hull Deductibles
Please Select
$250
$500
$1000
LIABILITY COVERAGE LIMITS:
Fishing Equipment coverages?
Please Select
1000
2500
5000
10,000
Primary Personal Effects coverage?
Please Select
1000
2000
3000
4000
5000
Sign & Glide
Yes
No
Referral:
If you weren't referred to us, how did you find us?
SUBMIT YOUR BOAT INSURANCE QUOTE
Should be Empty: