Boat Quote Request Form First Name Last Name Date of Birth Mailing Address Zip Year Make Model Primary Use ---Pleasure UseRacing/Speed ContestsBusiness Commercial UseRented or Leased to othersPrimary Residence Watercraft Zip Location Was the vehicle purchased or leased? ---PurchasedLeased Are you the original owner of the vehicle? YesNo Is the watercraft co-owned by someone living in a separate household YesNo What year was this vehicle acquired Market Value of vehicle Would you like to insure your trailer? YesNo Gender MaleFemale Marital Status ---Single/SeparatedMarried/Civil Union/Domestic Partnership/Widowed Residency Primary Residence ---Own House/CondominiumOwn Manufactured HomeRentOther Moved in the last 2 months? ---NoYes - Moved within the U.S.Yes - Moved from outside the U.S. Driving History Driver's License Status ---ValidPermitSuspendedNot LicensedForeign Driver's License Years of Boat Operating Experience Taken an approved watercraft safety course? YesNo Accidents, Violations, and Claims As a driver in the last 3 years, have you had any of the following regardless of fault (including automobile) Accidents, claims, or other damages you had to a vehicle? YesNo Tickets or Violations YesNo Additional Information Primary Email Address When would you need coverage?
