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Watercraft Quick Quote Form
Agency Name: Agency Number:
Producer Name: Mooring Zip Code:
Producer Email:
Owner Information
Name:
Date of Birth: Social Security Num: Mailing Zip Code:
Address: City/County:
Marital Status:  Do you own your own home: 
Is the watercraft titled in the name of a company or corporation?   If yes, explain:
Boat Information
Manufacturer: Year: Model: Current Value:
Hull Type: Hull Material: Propulsion:
Length: Speed: Weight: Number of Engines:
Total Horsepower: Fuel Type: Purchase Price: Purchase Date:
Navigation Teritory: Distance Offshore:
Distance From Residence: Mooring Zip Code:
Safety Equipment (check all that apply):        
       
Operator Information
Is the Owner the Primary Operator? # of years Boating Experience:
Motor Vehicle Violations (last 3 yrs):
All Marine Losses:
Experience (if boat is >65mph):

Secondary Operator Name: # of years Boating Experience:
Motor Vehicle Violations (last 3 yrs):
All Marine Losses:
Experience (if boat is >65mph):
Secondary Operator Date of Birth:
Coverages & Limits
Watercraft & Equipment: $ Deductible: Settlement Type:
Liability Limit: Uninsured Boater:   Up to $500,000 (Included)   Med Pay:
Personal Effects: Polution:   $500,000 (Included)   Towing:
Trailer: $ Fishing Equipment: Boat Lift:
Coverage Amount:
Watersports Liability (BI/PD coverage for skiing, towing, etc.):
Additional Information:


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