Your Name



Address



City



County



State



Zip Code



Telephone Number



Fax Number



E-Mail Address

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Watercraft Description

 

Year, Make & Model 

 

Description 
        

Runabout
Sailboat
Pontoon
Houseboat
Cabin Cruiser
Bass/Fishing
Personal Watercraft

Propulsion Type   
  

Inboard
Outboard
Inboard/Outboard

Number of Motors 
  
 

Length
            
  

Maximum Speed  
     

Total Horsepower  

Modified for Performance ?  Yes  No

Cost New 

Is a trailer included in the Cost New ? Yes  No

Storage Location 

 

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Please list all accidents (including not-at fault accidents) and violations for the last 3 years:

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Coverages:

Liability Limit - Bodily Injury

$15,000 per person, $30,000 each accident $25,000 per person, $50,000 each accident $50,000 per person, $100,000 each accident $100,000 per person, $300,000 each accident $250,000 per person, $500,000 each accident

Property Damage

$10,000 each accident $25,000 each accident $50,000 each accident $100,000 each accident

Medical Expense Coverage

None $1,000 $2,500 $5,000

Uninsured Boaters

None $15,000 per person, $30,000 each accident $25,000 per person, $50,000 each accident $50,000 per person, $100,000 each accident $100,000 per person, $300,000 each accident $250,000 per person, $500,000 each accident

Comprehensive Coverage
Deductible

No Coverage $100 deductible $200 deductible $250 deductible $500 deductible $1,000 deductible



Collision Coverage
Deductible

No Coverage $100 deductible $250 deductible $500 deductible $1,000 deductible

Additional Coverage:

Include Coverage for Towing & Labor ? Yes No

Include Total Loss Replacement Cost Coverage ? Yes No

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Have you taken an approved Safety Course

within the last 3 years? Yes No

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