Boat Insurance Quote - InsuranceQuote.net Sample Form

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Agency Name Here
A few lines of text describing your agency

Agency Street Address
Agency City, Zip State
Agency toll free Phone (if applicable)
Agency Phone
Agency Fax
Agency E-mail:info@YourAgency.com

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Boat Insurance Quote
Completely fill out and submit this form to our agency to receive an accurate quote. You MUST provide at least one method of contact to receive a quote from our agency.
Personal Information

Name (required)

E-Mail Address (required)

Address

City/State/Zip(required)

Home Phone

Work Phone

Fax

Operators

First Name Birthdate Has Operator completed Coast Guard Auxiliary or Power Squadron course?

#1

#2

#3

Boat Information (ALL INFO REQUIRED)

Boat Currently Insured?

Policy Expires Month/Year

Current/Desired Policy Deductible

Boat Type

Use

Where is vessel stored

Waters Navigated

Used for Racing?

Hull

Make/Model

Hull Type

Length

Estimated Market Value

Year Built

Max Speed (in MPH)

Personal Effects? (Amount)

Misc Boating Equip? (Amount)

Engine(s)

#1 Engine

Make Year

Type

Fuel Type

Est. Value (O/B Only)

Horse Power

#2 Engine

Make Year

Type

Fuel Type

Est. Value (O/B Only)

Horse Power

Trailer?

If Yes

Make

Value

Liability Coverage

Liability

Medical Payments

Water Ski Medical Needed

Explain all yes answers below

Has any listed operator been involved in a boating accident within the past 5 years?

Has your boat and / or equipment suffered damage from any cause within the past 5 years ?

Has any listed operator been involved in an auto accident or received a moving traffic citation in the past 3 years?

Remarks

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Operators
First Name	Birthdate	Has Operator completed Coast Guard Auxiliary or Power Squadron course?
#1
#2
#3