Water Craft Insurance Request
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First Name*:

 MI:
 Last Name*:
 Suffix
Street Address*:

 Apartment Number/ Unit P.O. Box
City*:
 State:
California 		Zip Code*:
Home Telephone*:
 Work Telephone:
 Fax Telephone:
Email Address:
(If you will like an email response)
Prior Insurance company    Expiration: Example 08/20/1970
Date of birth:     Gender:
Social Security #:
Operator Information
Name
DOB
Gender
Marital Status
SS#
Driver's License
State
Relationship
Owner
Operator
Is the watercraft titled in a business name?
Accidents / Violations
Please explain any auto accidents, marine losses, and violations. (Include dates, who was at fault, description, and amount of loss.
Watercraft Information
Unit
Unit type
year
Manufacturer
Model
HP & CC
Serial #
Current Value
1
2
3
Accessories installed on your personal watercraft
Unit
Description
Value
1
2
Trailer Information
Trlr
Model year
Manfacturer
Model
Serial Number
Current Value
1
2
Coverage Options

Comprehensive package:
Includes physical damage with $250 deductible./$500 theft deductible
Example 20/40/20 =
$20,000 Per person limit for bodily injury
$40,000 Per occurrence limit for bodily injury
$20,000 Property damage
Liability Only:

Options Coverages:
Medical Payments: $1,000 $2,500 $5,000 $10,000
Uninsured Watercraft: 10/20 15/30 20/40 25/50 30/60 50/100 100/300 250/300
Towing and Assistance: $500
Optional Deductible: $500 or $1000
Additonal Comments:
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.