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Personal Watercraft
Name Insured
First MI. Last
*
Street
*
City, State, ZIP
*
Home Phone
*
Business Phone
*
Email Address
*
Social Security Number
*
DOB
*
Driver's License Number
*
Marital Status
*
Occupation
*
Years Vessel Experience
*
Additional Operator
Name
*
Gender
*
Select One
Male
Female
Social Security Number
*
Driver's License Number
*
DOB
*
Years Vessel Experience
*
Hull
Year
*
Make
*
Model
*
Length
*
ACV
*
Engine
Year
*
Make
*
ACV
*
Horsepower
*
Max Speed
*
Inboard/Outboard
*
Class
*
Deck
Cabin Cruiser
Runabout
Cuddy
Flats
Trailer
Year
*
Make
*
ACV
*
Coverages
Bodily Injury
*
Select One
10,000/20,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
Property Damage
*
Select One
10,000
25,000
50,000
100,000
Uninsured Boat Coverage
*
Select One
0
10,000/20,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
Medical Pay
*
Select One
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
Comprehensive Deductible
*
Select One
0
25
50
100
200
250
500
1,000
Collision Deductible
*
Select One
0
25
50
100
200
250
500
1,000
Boat Towing
*
Select One
Yes
No
