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On-Line Boat & Jet Ski
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data

Your Name:
Street Address:
City:
State: (Must be Virginia)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Boat Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)
 
Is this Boat Co-owned?
(If yes, list all owners names)

OPERATOR INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Number of Years
Boating Experience:

OPERATOR INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Number of Years
Boating Experience:

VESSEL & UNDERWRITING INFORMATION
Year of Boat: Make & Model
(be specific):
 
Boat Length: Hull Type
(wood, Metal,
fiberglass, etc):
 
Max. Speed
(in MPH):		 Market Value: $
 
Engine Make: Engine Type:
(Inboard, I/O, Jet)
 
Engine Horse
Power:		 Fuel Type:
(Gas, Diesel, etc.)
 
Trailer Cov.
Needed?		 Yes No Yr./Make/Model
of Trailer:
 
Trailer Value: $ Where is boat
moored or stored?
 
Describe waters
boat taken on?		 Describe boat
general usage?
(fishing, ski, etc.)

VESSEL COVERAGES:
Limits of
Liability:		 $15/30 BI / 10 PD $25/50 BI / 15 PD
$50/100 BI / 25 PD $100/300 BI / 50 PD
$250/500 BI / 100 PD
 
Hull Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Water Ski
Medical Coverage?		 Yes No   Uninsured
  Motorists Cov.?		 Yes No
 
Comments or Remarks:
(List additional drivers,
special coverages, etc. here)

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