Named
Insured
Name:
Address:
City/State/Zip:
/
/
Phone:
Fax:
Email:
Preferred
Response Method:
Email
Fax
Phone
Watercraft
Type
This
quote request is for a:
BOAT
JETSKI
Operator
Information
Name:
User
1
User
2
User
3
User
4
Date
of Birth:
User
1
User
2
User
3
User
4
Drivers
License #:
User
1
User
2
User
3
User
4
License
State of Issue:
User
1
Select State
Massachusetts
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Misissippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Washington
Washington D.C.
User
2
Select State
Massachusetts
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Misissippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Washington
Washington D.C.
User
3
Select State
Massachusetts
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Misissippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Washington
Washington D.C.
User
4
Select State
Massachusetts
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Misissippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Washington
Washington D.C.
Years
Watercraft Experience:
User
1
User
2
User
3
User
4
Minor
Violations Last 3 Years: (List Month/Year for each incident.)
"mm/yyyy, mm/yyyy,.."
User
1
User
2
User
3
User
4
Major
Violations Last 3 Years: (List Month/Year for each incident.)
"mm/yyyy, mm/yyyy,.."
User
1
User
2
User
3
User
4
At-Fault
Accidents Last 3 Years: (List Month/Year for each incident.)
"mm/yyyy, mm/yyyy,.."
User
1
User
2
User
3
User
4
Description
of Watercraft
Year:
Make:
Model:
Serial
#:
Max
HP (Boats) or CC (JetSkis)
"## HP" or "## CC"
Length:
feet
Max
Speed:
mph
New/Used
New
Used
Registration
#: (Boats)
1,2
or 3 Passenger: (JetSkis)
1 Passenger
2 Passenger
3 Passenger
State
of Navigation:
Select State
Massachusetts
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Misissippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Washington
Washington D.C.
Purchase
Date:
"mm/dd/yyyy"
Purchase
Price:
$
Describe
any permanently installed or custom equipment:
Description of Motors (Boats)
Year:
Motor
#1
Motor
#2
Make:
Motor
#1
Motor
#2
Serial
#:
Motor
#1
Motor
#2
HP:
Motor
#1
Motor
#2
Year
Rebuilt:
(if applicable)
Motor
#1
Motor
#2
Description
of Trailer(s)
Year:
"yyyy, yyyy, ..."
Make:
"make, make, ..."
Serial
#: "##, ## ..."
Additional Items On Board Boat
Miscellaneous
Equipment:
"Item Description, $ Value, Item Description, $ Value, ..."
Personal
Effects:
"Item Description, $ Value, Item Description, $ Value, ..."
Detailed Boat Information
Boat
Type:
Outboard
Inboard
Inboard/Outboard
Jet Powered
Sailboat
Houseboat
Pontoon
Other
Boat
Construction:
Fiberglass
Wood
Metal
Aluminum
Steel
Other
Area
of Navigation:
Inland Waters
Great Lakes
Gulf Coastal < 3 Miles
Gulf Coastal 3-25 Miles
Atlantic Coastal < 3 Miles
Atlantic Coastal 3-25 Miles
Pacific Coastal < 3 Miles
Pacific Coastal 3-25 Miles
SanFancisco Bay (not west of Golden
Gate)
Lake Powell/Mead
Yes
No
Is extended coastal navigation desired?
Garaging/Mooring
During Period of Use:
Driveway/Yard/Garage
Private Storage
Apt/Townhouse Lot
Mobile Home Park
Marina
Slip
Other
Garaging/Mooring
During Lay Up:
Driveway/Yard/Garage
Private Storage
Apt/Townhouse Lot
Mobile Home Park
Marina
Slip
Other
Watercraft
Losses in Last 3 Years
Date
of Loss:
Loss
1
"mm/dd/yyyy"
Loss
2
"mm/dd/yyyy"
Loss
3
"mm/dd/yyyy"
Cause
of Loss:
Loss
1
Loss
2
Loss
3
Describe
damage to watercraft and equipment:
Loss
1
Loss
2
Loss
3
Was
anyone injured? Please explain:
Loss
1
Loss
2
Loss
3
$
Amount of Damage:
Loss
1
$
Loss
2
$
Loss
3
$
General Boat Information
In
what state is the boat primarily navigated?
Select State
Massachusetts
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Misissippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Washington
Washington D.C.
How
many years has the principal operator maintained and operated a
watercraft?
Has
engine been turbocharged, supercharged, altered or modified in any
way for the purpose of enhancing speed or performance?
Is
this boat the primary residence of the insured?
Yes
No
Is
this boat titled in the name of or used in the course of the insured's
business?
Note: Coverage is limited to private pleasure use of owner.
Is
this boat owned by others in addition to the named insured?
Note: Maximum of three owners for coverage eligibility.
Is
craft permanently moored?
If yes, Where (Including Zip Code)
Is
this boat currently for sale by the insured?
Yes
No
Is
the insured boat used for water-skiing? (power boats only)
If yes, is water-skiing liability coverage desired?
Has
the principal operator of the boat completed either the US Coast
Guard Auxiliary or US Power Squadron introductory courses? (Completion
Certificate will be required)
Is
your motor's propeller construction other than stainless steel?
General
JetSki Information
Is
personal watercraft modified in any way to enhance speed or performance?
If yes, please explain.
Is
personal watercraft used in any race or exhibition?
Please Note - No coverage for race or exhibition.
Is
personal watercraft titled in the name of or used in the course
of the insured's business?
Note: Coverage is limited to private pleasure use of owner.
Is
personal watercraft currently held for sale and if so, how long
has it been for sale?
Where
will personal watercraft be stored when not in use? (Including Zip
Code)
Thank
You. You have completed the form. Add any general comments in the
box below, then click the "Submit" button. We will respond
to you promptly. Thank you for considering Ideal Insurance for your
insurance needs.
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