| About
You |
| *
Your First Name |
| *
Last Name |
| *
Email |
|
*
Email address (retype) |
| *
Street Address |
| *
City |
| * |
| *
County |
| *
Zip |
|
*
Phone (Day)
Ext.
|
|
Phone (Evening)
|
| Fax |
| /
/ *
What is your Birth Date (mm/dd/yyyy) |
Marital Status
Single
Married
Divorced
* |
| #
of Watercrafts to insure * |
| #
of Owners * |
Do you prefer liability coverage only?
Yes
No
* |
Maximum # of passengers?
4
or less More
than 4 * |
Any Personal Watercraft claims (3
years or less)?
Yes
No
* |
Any operators under the age of 14?
Yes
No
* |
Is Watercraft rented or leased to
others?
Yes
No
* |
Is this Watercraft used for racing?
Yes
No
* |
Is the engine(s) altered?
Yes
No
* |
Please specify Personal Watercraft
use:
Pleasure
Commercial * |
| #
of Marine-related Major violations (past 3 years)
* |
| #
of Marine-related Minor violations (past 3 years)
* |
| #
of Marine-related At-fault accidents (past 3 years)
* |
Do you have your home or auto insured
with Farmers or Foremost?
Yes
No
|
| Manufacturer* |
| Model
* |
| Model
Year * |
|
Engine
Displacement: *
0-600
601-700
701-850
851-1099
1100
+
|
| Unit
value * |
| Trailer
Value (to nearest 100) * |
| Accessories
to nearest 100 |
Towing?
Yes
No
* |
|
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 Comprehensive/Collision Deductible
preferences (if desired).
100
250
500
1000
|
|
Please
choose your Medical Payment coverage.
1000
2500
5000
10,000
None
|
