Inboard Motor Boat or Stern Drive Quote
GENERAL INFORMATION
Note- Coverage can not be bound or altered by this submission
First name
*
Last name
*
Address
City
State
Zip
Daytime telephone number
Alternate telephone number
Email address
*
DRIVER INFORMATION
Name
Sex
Male
Female
Date of Birth
Yrs. Licensed to Drive Boat
Less than 1
1
2
3
4
5
More than 5
License Number
State Licensed
NJ
other
Married
No
Yes
Coast Guard Safety Course
No
Yes
At Fault Accidents *
0
1
2
3
4
More than 4
Number of Motor Vehicle Tickets *
0
1
2
3
4
5
6
7
8
9
More than 9
Number of Boating Incidents *
0
1
2
3
4
5
6
7
8
9
More than 9
* In The Past 3 Years
BOAT INFORMATION
Year
Manufacturer
Model
Length
Hull ID Number
Hull Material
Fiber
Aluminum
Wood
Fiber over wood
Steel
Composite
Other
Protective Devices
None
Automatic Fire Extinguisher
Alarm High Water/Fire/Theft
Central Station Monitor
No Strike Lightning System
Home Made?
No
Yes
Used for Racing
No
Yes
Type of Power
Sail no Engine
Sail Small Engine
Inboard
Inboard/Outboard
Jet Drive
Total Horsepower
Type of Fuel
Gas
Electric
Diesel
No Motor
LIABILITY COVERAGE
Bodily Injury Liability
15,000/30,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
Property Damage Liability
5,000
10,000
25,000
50,000
100,000
Estimated Credit Rating
Excellent
Very Good
Good
Questionable
HULL INSURANCE
Want Hull coverage?
Yes
No
If yes, enter Boat Value
TRAILER INSURANCE
Liability for the trailer, while in tow, is covered by the towing vehicle.
Be sure the towing vehicle has adaquate insurance.
Want Trailer Physical Damage coverage?
Yes
No
If yes, enter Trailer Value
COMMENTS
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