| On-Line Boat Insurance Quote Form |
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Your Personal Data: |
| *Your Name |
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| *Street Address |
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| *City |
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| *State |
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| *Zip Code |
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| *E-Mail |
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| E-Mail (repeat) |
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| *Phone |
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| fax(optional) |
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| Marital status |
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| Homeowner? |
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Boat Currently Insured?
(If yes, list carrier, and # of years continuous, if not, leave blank or write "no") |
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is the boat co-owned?
(If yes, list all owner's names) |
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Operator Information #1 |
| *Name |
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| *Birthdate |
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| sex |
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| *# Years US Licensing |
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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 (enter 0 if none) |
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| *Number & Type of MINOR Accidents last 3 years (enter 0 if none) |
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| *Number & Type of MAJOR Accidents last 3 years (enter 0 if none) |
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| Number of years boating experience |
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Operator Information #2 (if none leave blank) |
| Name |
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| Birthdate |
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| sex |
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| # Years US Licensing |
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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 (enter 0 if none) |
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| Number & Type of MINOR Accidents last 3 years (enter 0 if none) |
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| Number & Type of MAJOR Accidents last 3 years (enter 0 if none) |
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| Number of years boating experience |
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Vessel & Underwriting Information |
| Year of boat |
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| Make and model of boat |
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| Length of boat |
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| Hull type |
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| Max. speed in MPH |
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| Market value (in $) |
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| Engine make |
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| Engine type (Inboard, I/O, Jet) |
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| Engine Horse Power |
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| Fuel type (Gas, Diesel, etc.) |
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| Trailer Coverage needed? |
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| Year, make and model of Trailer |
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| Trailer value (in $) |
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| Where is boat moored or stored? |
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| Describe waters boat taken on |
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| Describe boatgeneral usage? (fishing, ski, etc.) |
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Vessel coverage |
| Limits of Liability |
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| Hull Coverage |
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| Water Ski Medical Coverage? |
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| Uninsured Motorists Cov.? |
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| Comments or remarks |
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| *Send my quotation via |
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* denotes required field |
All content is property Thurston Insurance (2006) | Privacy Statement Agents