| *
County |
| *
Zip |
|
*
Phone (Day)
Ext.
|
|
Phone (Evening)
|
| Fax |
| /
/ *
What is your Birth Date (mm/dd/yyyy) |
Marital Status
Single
Married
Divorced
* |
| # Years
of Boat Ownership * |
| / Length
of Boat (Feet / Inches) * |
Pontoon?
Yes
No
* |
|
What
is the Power Type? *
Inboard/Outboard
Outboard
Sailboat
Jet
Outboard
Jet Drive
No
Engine
|
| Manufacturer* |
| Model
* |
| Model
Year * |
|
What
is the Hull Material? *
Fiberglass
Aluminum
Fiberglass
over wood
Steel
Composite
Other
|
| Hull
Value * |
| Trolling
Motor Value (if applicable) |
Valuation Method
Agreed
Value Actual
Cash Value (ACV) * |
|
Deductible
Preference *
1%
2%
3%
5%
|
Towing & Assistance?
Yes
No
* |
|
Please
choose your Trailer Deductible *
250
500
|
| Personal
Property Coverage Desired (up to $10,000) |
Personal Property Replacement Cost
Coverage
Yes
No
No
personal property coverage * |
|
Please
choose the amount of liability desired *
15/30/10
25/50/25
50/100/50
100/300/100
250/500/100
500/500/500
|
|
Please
choose the amount of uninsured/underinsured motorists coverage desired
*
15/30
25/50
50/100
100/300
250/500
500/500
None
|
|
Please
choose your Medical Payment coverage
1000
2500
5000
10,000
None
|
| #
of Marine-related At-fault accidents (past 3 years)
* |
| #
of At-fault accidents Motorized Vehicles (past 3 years)
* |
| #
of Major violations (past 3 years)
* |
| #
of Minor violations (past 3 years)
* |
Have you had watercraft insurance
during the past 12 months?
Yes
No
* |
Loss-free preceding year
Yes
No
* |
Do you have your home or auto insured
with Farmers or Foremost?
Yes
No
|
