Request for Boat Insurance Quote

1
Agency Name* This field is required.
LSI
2
Transaction ID
3
LOB* This field is required.
4
Producer Names* This field is required.
Please Select
Please Select
Joe
Ella
Craig
Mary
May
Josh
Sam
Jeff
Jessica
Louie
RJ
Jacky
Brian
Mika
Jason
Trixie
Jay
Dave
5
Assigned P-Card* This field is required.
6
For Edit Submission* This field is required.
7
Date* This field is required.
Month
Day
Year
8
How did you hear about us* This field is required.
I'm an existing client
I was referred by someone
LSI Website
Google search
I don't know
Other
9
Please explain* This field is required.
10
Who were you referred by* This field is required.we just want to thank them for thinking of us
Hit next if unknown
11
What is your full name* This field is required.Enter your legal name as it appears on your driver license
First Name
Last Name
12
What is the best phone number to get a hold of you.* This field is required.
13
What is your email address* This field is required.This is so we can send you a formal proposal & policy information for your review
example@example.com
14
How many total drivers including yourself will be covered by this policy* This field is required.
Please Select
Please Select
1
2
3
4
15
How many total boat/yachts will be covered by this policy* This field is required.
Please Select
Please Select
1
2
16
What is your date of birth* This field is required.As listed on your driver license
17
What is your gender* This field is required.As listed on your driver license
Male
Female
18
What is your marital status* This field is required.
Single
Married
Domestic Partner
Widowed
Separated
Divorced
19
What is the address where the boat is garaged or stored* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
20
Do you receive mail at this address* This field is required.
YESNO
21
What is your mailing address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
22
What is your driver license number* This field is required.
23
Is this a California driver license* This field is required.Issued to you by Department of Motor Vehicles
YESNO
24
What state issued you the license* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
IllinoisIndiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
MontanaNebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
PennsylvaniaRhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
25
What is your full name of the 2nd driver* This field is required.Enter your legal name as it appears on your driver license
First Name
Last Name
26
What is the relationship to the first applicant* This field is required.
Child
Domestic Partner
Employee
Parent
Relative
Other
27
What is the date of birth of the 2nd driver* This field is required.As listed on your driver license
28
What is the gender of the 2nd driver* This field is required.As listed on your driver license
Male
Female
29
What is the marital status of the 2nd driver* This field is required.
Single
Married
Domestic Partner
Widowed
Separated
Divorced
30
What is the driver license number of the 2nd driver* This field is required.
31
Is this a California driver license* This field is required.Issued to you by Department of Motor Vehicles
YESNO
32
What state issued the license* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
IllinoisIndiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
MontanaNebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
PennsylvaniaRhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
33
What is your full name of the 3rd driver* This field is required.Enter your legal name as it appears on your driver license
First Name
Last Name
34
What is the relationship to the first applicant* This field is required.
Child
Domestic Partner
Employee
Parent
Relative
Other
35
What is the date of birth of the 3rd driver* This field is required.As listed on your driver license
36
What is the gender of the 3rd driver* This field is required.As listed on your driver license
Male
Female
37
What is the marital status of the 3rd driver* This field is required.
Single
Married
Domestic Partner
Widowed
Separated
Divorced
38
What is the driver license number of the 3rd driver* This field is required.
39
Is this a California driver license* This field is required.Issued to you by Department of Motor Vehicles
YESNO
40
What state issued the license* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
IllinoisIndiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
MontanaNebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
PennsylvaniaRhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
41
What is your full name of the 4th driver* This field is required.Enter your legal name as it appears on your driver license
First Name
Last Name
42
What is the relationship to the first applicant* This field is required.
Child
Domestic Partner
Employee
Parent
Relative
Other
43
What is the date of birth of the 4th driver* This field is required.As listed on your driver license
44
What is the gender of the 4th driver* This field is required.As listed on your driver license
Male
Female
45
What is the marital status of the 4th driver* This field is required.
Single
Married
Domestic Partner
Widowed
Separated
Divorced
46
What is the driver license number of the 4th driver* This field is required.
47
Is this a California driver license* This field is required.Issued to you by Department of Motor Vehicles
YESNO
48
What state issued the license* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
IllinoisIndiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
MontanaNebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
PennsylvaniaRhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
49
What bodily injury limits do you wish to have* This field is required.This will pay for damages you cause to someone else. You can find this in your exisiting or prior insurance documents
Bare Minimum (15,000 per person / 30,000 per accident)
Basic (25,000 per person / 50,000 per accident)
Basic Plus (50,000 per person / 100,000 per accident)
Standard (100,000 per person / 250,000 per accident)
Premier (250,000 per person / 500,000 per accident)
Premier Plus (500,000 per person / 500,000 per accident)
50
What is the 1st type of boat/yacht* This field is required.
Please Select
Please Select
Bass Boat
Bay Boat
Bowrider
Center Console
Convertible Fishing Boat
Cruiser
Cuddy Cabin
Deck Boat
Dinghy
Downeast Cruiser
Dual Console
Express Fisherman
Fish 'n Ski Boat
Flats Boat
High Performance Boat
Houseboat
Inflatable Boat
Jet Boat
Jon Boat
Multi-species Boat
Pilothouse Boat
Pontoon Boat
Power Catamaran
PWC (Personal Watercraft)
Rigid Inflatable
Runabout
Sedan Bridge Boat
Ski and Wakeboard Boat
Skiff
Utility Boat
Walkarounds
Jetski/ Ski doo
51
What is the usage of the 1st boat/yacht* This field is required.
Pleasure Use only
Used as a Residence
For Hire (Rented Out)
52
Enter the information for the 1st boat/yacht* This field is required.Note - The Hull ID will produce the most accurate rate since there can be big differences between models
I have the Hull ID number to enter now
I do not have the Hull ID now, will text it to 510-962-4377
I do not have the Hull ID , will email it to Service@Lsiagency.com
Quote using Year, Make, Model, and Submodel (Rate is not accurate)
53
Enter the year, make, model, and submodel* This field is required.
Year
Make
Model
Sub Model
54
What is the Hull ID of the 1st boat/yacht* This field is required.
55
What is the actual cash value of the boat/yacht* This field is required.
56
What is the propulsion type of the boat/yacht* This field is required.
Inboard
Outboard
Inboard / Outdrive
Water Jet
57
What are the number of motors of the boat/yacht* This field is required.
1
2
3
58
What is the horsepower per motor of the boat/yacht* This field is required.
59
What is the fuel type of the boat/yacht* This field is required.
Gasoline
Diesel
Electric
60
What is the maximum speed of the boat/yacht* This field is required.
61
What is the length (feet) of the boat/yacht* This field is required.
62
What is the ownership type of the boat* This field is required.
Owned (No Lien)
Financed (Making Payments)
Leased
63
What is the purchased date of the boat/yacht* This field is required.
64
Do you want to cover the value of the boat/yacht* This field is required.All the boats will be covered for liability automatically. You just need to clarify if you want to cover the market value of the boat.
Yes (give me full coverage)
No (I just need liability for this boat/yacht)
65
What is the 2nd type of boat/yacht* This field is required.
Please Select
Please Select
Bass Boat
Bay Boat
Bowrider
Center Console
Convertible Fishing Boat
Cruiser
Cuddy Cabin
Deck Boat
Dinghy
Downeast Cruiser
Dual Console
Express Fisherman
Fish 'n Ski Boat
Flats Boat
High Performance Boat
Houseboat
Inflatable Boat
Jet Boat
Jon Boat
Multi-species Boat
Pilothouse Boat
Pontoon Boat
Power Catamaran
PWC (Personal Watercraft)
Rigid Inflatable
Runabout
Sedan Bridge Boat
Ski and Wakeboard Boat
Skiff
Utility Boat
Walkarounds
Jetski/ Ski doo
66
What is the usage of the 2nd boat/yacht* This field is required.
Pleasure Use only
Used as a Residence
For Hire (Rented Out)
67
Enter the information for the 2nd boat/yacht* This field is required.Note - The Hull ID will produce the most accurate rate since there can be big differences between models
I have the Hull ID to enter now
I do not have the Hull ID now, will text it to 510-962-4377
I do not have the Hull ID, will email it to Service@Lsiagency.com
Quote using Year, Make, Model, and Submodel (Rate is not accurate)
68
Enter the year, make, model, and submodel* This field is required.
Year
Make
Model
Sub Model
69
What is the Hull ID of the 2nd boat/yacht* This field is required.
70
What is the actual cash value of the 2nd boat/yacht* This field is required.
71
What is the propulsion type of the 2nd boat/yacht* This field is required.
Inboard
Outboard
Inboard / Outdrive
Water Jet
72
What are the number of motors of the 2nd boat/yacht* This field is required.
1
2
3
73
What is the horsepower per motor of the 2nd boat/yacht* This field is required.
74
What is the fuel type of the 2nd boat/yacht* This field is required.
Gasoline
Diesel
Electric
75
What is the maximum speed of the 2nd boat/yacht* This field is required.
76
What is the length (feet) of the 2nd boat/yacht* This field is required.
77
What is the ownership type of the 2nd boat/yacht* This field is required.
Owned (No Lien)
Financed (Making Payments)
Leased
78
What is the purchased date of the 2nd boat/yacht* This field is required.
79
Do you want to cover the value of the 2nd boat/yacht* This field is required.All the boats will be covered for liability automatically. You just need to clarify if you want to cover the market value of the boat.
Yes (give me full coverage)
No (I just need liability for this car)
80
Do you want to transfer the information from this P-Card to the matching CPA* This field is required.Note: This will transfer the information from this form (Purl) to the matching CPA to help you shop all the carriers and determine the best options.
Help me find a Market Now.
No - Not right now
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