AT THIS TIME WE CAN ONLY QUOTE THIS COVERAGE FOR TEXAS RESIDENTS.
PLEASE FILL OUT COMPLETELY.
First and Last Name Phone Number Fax Number Email Address Work Number Is this for: Ind/Family Partnership Corporation Previous/Current Policy Number Current Ins. Co. None Make Sea Doo Kawasaki Yamaha Polaris Tigershark Other Model Year Trailer Coverage Include None Double Custom HP Stated Value Trailer Value Year Purchased Purchased New Pre-Owned Is the craft financed No Yes Previous PWC Owned Navigated year round No Yes If no, laid up form what month to what month: From Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec to Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Laid up On Shore Afloat On Lift PREMIUM DISCOUNTED FOR A LAY-UP PERIOD Used in Fresh Water Salt Water Both Overnight Storage Lift Driveway Parking lot Garage Yard Street Prior Losses None Theft Submerged Object Injury Engine Collision Other If any losses: Yr. of Loss $ Paid Yr. of Loss $ Paid Liability Limit Requested $10,000 $25,000 25/50/15 $50,000 $100,000 $300,000 $500,000 $1,000,000 $2,000,000 None Deductible Requested $500 $1,000 Liability Only No Yes All Programs Include*: Uninsured Boaters Liability; Medical Payments; Towing/Roadside Assistance; Agreed Value ACV; No Installments; Minimum Annual Premium is $175; A Minimum Earned Premium (no refunds after 30 days); No Commercial Use (e.g. Rental); No Racing.
Who will be operating this craft? Boating Experience Name/Age Occupation #Tkts #Acc Years Boating Courses 0 1 2 3 4 5+ 0 1 2 3 4 5+ 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5+ 0 1 2 3 4 5+ 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5+ 0 1 2 3 4 5+ 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5+ 0 1 2 3 4 5+ 0 1 2 3 4 5 6 7 8 9 10+ Date of Birth of YOUNGEST Operator **$2,500 ded. & $10,000 max liab. for any operator without a valid driver's license. Have any of the above persons received a DUI No Yes If so, who and when
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