WATERCRAFT INFORMATION SHEET
Please FAX completed form to Dave at (201) 652-0721
Name: __________________________________ Today’s Date: ____________________
Mailing Address: _____________________________________________________________
Telephone Number(s): HOME ___________ CELL ____________ WORK _____________
Please complete the following on ALL licensed drivers in the household who will be included for quoting:
Name Date of Birth Soc. Sec. # Driver’s License # State M/F Year Marital
Licensed Status
Watercraft Information:
Watercraft Year Make Model VIN # Weight Length Hull Material Coverage
Amount
#1 ________________________________________________________________________
Motor Information:
Motor Year Make Model VIN # Power Max M.P.H. Fuel Type Coverage
Amount
#1 ________________________________________________________________________
#2 ________________________________________________________________________
Trailer Information:
Trailer Year Make Model VIN # Coverage Amount
#1 ________________________________________________________________________
Marina/Navigation Territory/Storage Information:
Marina Name Address Navigation Territory Storage Location Out of Water
#1 ________________________________________________________________________
Are any watercraft used for Business? ___
Do you presently have Insurance? YES __ NO ___ If NO, date last coverage ended? _________
Prior Insurance Company Name ________________ Reason for Cancellation _______________
How many years have you had continuous insurance? __________________________________
Are any listed operators a member of the Coast Guard? YES ___ NO ___
Have you owned any prior watercrafts? YES ___ NO ___
If YES, please state year, make and models of prior watercrafts owned:
Does the watercraft have any of the following: Automatic Built-in Fire Extinguisher ___
Navigation Equipment ___ Radar ___ Depth Finder ___ LORAN ___ Vapor Detection
System ___ VHF Ship to Shore Radio or Telephone ___ Other __________________________
List below, ANY CLAIMS or ACCIDENTS, in the last 5 years, for ANY operators on this policy.
How did you hear of our Agency? _________________________________________________
Attach required surveys to form.
WE WILL NEED TO ORDER AN INSURANCE SCORE FOR QUOTING. PLEASE INITIAL WHERE INDICATED FOR PERMISSION TO ORDER SAID DOCUMENT.
X _________