January 19, 2019

Boat/PWC Quote

How Did You Hear About Us?
How Did You Hear About Us? *  ?
Insured Information
First Name *
Middle Initial
Last Name *
Name Suffix
Home Phone
Work Phone
Cell Phone
Email *
Preferred Contact
Mailing Address *
City *
State California
Zip Code *
Primary Residence (If "Other" is selected, please explain)
Insured moved in last 60 Days? * Yes  No
Prior Mailing Address (Required if answered "Yes" to previous question)
Current Insurance
Do you presently have Auto Insurance? Yes  No
Company Name
Renewal Date
Annual Premium
Have you been cancelled or non-renewed in the past three years? * Yes  No ?
Vehicle(s) Information
Vehicle Type *  ?
Do you have the Vehicle Identification Number (VIN)/Serial Number (If "Yes", please enter the number) * Yes  No ?
Year *
Make *
Model *
Engine CC Size  ?
Vehicle Modifications *  ?
Zip Code for the Primary Location for your vehicle. *  ?
Vehicle Use *  ?
Annual Mileage *  ?
If Commute is selected, enter # of miles one way to work/school.
If Commute is selected, enter # of commute days per week
Do you have a 2nd Vehicle? * Yes  No
Vehicle Type  ?
Do you have the Vehicle Identification Number (VIN)/Serial Number (If yes, please enter the number) Yes  No ?
Year
Make
Model
Engine CC Size  ?
Vehicle Modifications  ?
Zip Code for the Primary Location for your vehicle  ?
Vehicle Use  ?
Annual Mileage  ?
If Commute is selected, enter # of miles one way to work/school.
If Commute is selected, enter # of commute days per week
Drivers
First Name *
Middle Name *
Last Name *
Suffix
Birth Date
Gender * Male  Female
Marital Status *
Relationaship to Insured *
Driver's License Status *  ?
Valid Motorcycle License/Endorsement? * Yes  No ?
Motorcycle License/Endorsement Date (Required if answered "Yes" to previous question)
Does driver require an SR-22 filing? * Yes  No ?
Approved Safety Course Completion in past three years? * Yes  No ?
Mature Driver Course completion? * Yes  No ?
How many years have you been licensed to drive an automobile? *
What is the total number of years driving experience you have had as a licensed motorcyclist? *  ?
Belong to a motorcycle association?  ?
Do you have a 2nd Driver? Yes  No
First Name
Middle Name
Last Name
Suffix
Birth Date
Gender Male  Female
Marital Status
Relationship to Insured (If "Other" is selected, please explain)
Driver license status  ?
Valid Motorcycle License/Endorsement? Yes  No ?
Motorcycle License/Endoresment Date (Required if answered "Yes" to previous question)
Does driver require an SR-22 filing? Yes  No ?
Approved Safety Course completion in past three years? Yes  No ?
Mature Driver Course completion? Yes  No ?
How many years have you been licensed to drive an automobile?
What is the total number of years driving experience you have had as a licensed motorcyclist?  ?
Belong to a motorcycle association?  ?
Accidents, Violations, and Claims
Please provide all accidents, violations, and comprehensive claims, regardless of fault, that occurred in the last three years. Also include all Driving Under the Influence violations that occurred on or after 1/1/01. Please include Incident along with Incident Date.
  Incident Type ? Incident Date
1.
2.
3.
4.
5.
Other Drivers
Please provide the names and birthdates of any other residents in your household licensed to drive.
  Name Birth Date Do any drivers belong to a Boat/PWC association? ?
1.
2.
3.
4.
5.
Coverages
Bodily Injury Liability
Property Damage Liability
Medical Payments
Uninsured Motorist Liability
Uninsured Motorist Property
Underinsured Motorist Liability
Underinsured Motorist Property
Comprehensive Deductible
Collision Deductible
Towing & Labor Yes  No
Vehicle(s) Information
Hull Material  ?
Number of Motors  ?
Total Horsepower  ?
Propulsion Type  ?
Does the boat have an exposed engine? Yes  No ?
Modified For Enhanced Performance? Yes  No ?
Maximum speed  ?
Would you like to insure your trailer selections? Yes  No ?
Market Value of Watercraft
What should I include?)		  ?
Does the value include a trailer? Yes  No ?
Original Owner Yes  No ?
Storage/Mooring ZIP code  ?
Is Boat/PWC kept at your place of residence? *
Question is for marketing or research purposes only. It will not affect your rate		 Yes  No
Select location at your place of residence
Question is for marketing or research purposes only. It will not affect your rate
Boat/Pwc Use  ?
Multi-owner Yes  No ?
Idle Assisted Steering Yes  No ?
Safety Course Yes  No ?
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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