PERSONAL WATERCRAFT WORKSHEET

First Name: Last Name: Garaging Address: Garaging City: Garaging State: California Garaging Zip Code: Phone Number: Fax Number: E-Mail Address:    MAILING ADDRESS (OPTIONAL)   Mailing Address If Different from Garaging:   Mailing City: Mailing State: Select...AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Mailing Zip Code:   DRIVER INFORMATION     Driver One Driver Two Driver Three Driver Four First Name Birthdate Sex Male Female Male Female Male Female Male Female Marital Status Single Married Divorced Widowed Separated Single Married DivorcedWidowed Separated Single MarriedDivorcedWidowed Separated Single Married Divorced Widowed Separated State Licensed Yrs Boating Experience Occupation WATERCRAFT INFORMATION     Boat Trailer Motor Year Make Model Type (ie; JetSki, Jet Drive Boat)? Single Axle Dual Axle Three Axle Jet Pump Identification Serial Number Cost New Value Hours Used Each Year Under 5051-100 101-200 201-300 301-400 401-500 500+ Horsepower CC or Motor Size 0-300301-500501-700701+ Boat Length ft. Ownership Leased Paid-Off Financed VIOLATION INFORMATION   Last 3 Yrs (Minors) Last 5 Yrs (Majors) Driver 1 Driver 2 Driver 3 Driver 4 Minor Violations - Speeding, Turn, Stop Sign, Red Light, etc. None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 Accidents - Non Chargeable None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 Accidents - Chargeable None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 Major Violations - Drunk Driving, Reckless, Hit & Run, etc. None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 COVERAGE INFORMATION     Bodily Injury Property Damage Personal Liability 15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000 5,000 10,000 25,000 50,000 100,000 Uninsured Motorist None 15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000 None 3,500 Deductible Waiver Medical Payment: No Coverage 1,000 2,000 2,500 5,000 10,000 15,000 20,000 25,000 50,000 100,000   DEDUCTIBLE INFORMATION     Boat & Motor Trailer Comprehensive (Theft) No Coverage 250 500 1,000 1,500 2,000 No Coverage 250 500 1,000 1,500 2,000 Collision No Coverage 250 500 1,000 1,500 2,000 No Coverage 250 500 1,000 1,500 2,000 MISC INFORMATION   Current Insurance Company:   Expiration Date: Current Premium $: Questions or Comments to help the Agent:    Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.