Tell us about you.
Name: Home Phone:
Street Address: Work Phone:
City: Email Address:
State: Zip:    


Who will be operating the craft?
  User 1 User 2 (optional)
Name:
Date of Birth:
Drivers License Number:
State Licensed By:
Years Watercraft Experience:
Minor Violations Last 3 Years:  (list month / year for each incident):
Major Violations Last 3 Years:  (list month / year for each incident):
At Fault Accidents Last 3 Years:  (list month / year for each incident):


Tell us about your watercraft.
Year:
Make:
Model:
Serial Number:
Max HP (Boat) or CC (Jet Ski):
Length:
Max Speed:
New / Used:
Registration Number:
1, 2, or 3 Passenger (Jet Skis):
State of Navigation:
Purchase Date:
Purchase Price:
Describe any Permanently Installed or Custom Equipment:
Miscellaneous Equipment: 
Personal Effects: 
Description of Trailer (Year, Make, Serial Number):


Fill out only if requesting a quote for a Jet Ski.
  Answer & Description If Yes
Is Personal Watercraft Modified in Any Way to Enhance Speed or Performance? 
Is Personal Watercraft Used in Any Race or Exhibition?
Is Personal Watercraft Titled in the Name of or Used in the Course of the Insured's Business?
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):


Fill out only if requesting a quote for a boat.
Boat Type:
Boat Construction:
Areas of Navigation:
Atlantic Coastal < 3 Miles
Atlantic Coastal 3-25 Miles
Inland Waters
Great Lakes
Is extended coastal navigation desired?
Garaging/Mooring During Period of Use:
Garaging/Mooring During Lay Up:
In What State is the Boat Primarily Navigated?
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?
Is This Boat Titled in the Name of or Used in the Course of the Insured's Business?
Is This Boat Owned by Others in Addition to the Named Insured?
Is Craft Permanently Moored? If yes, Where (Including Zip Code):
Is This Boat Currently for Sale by the Insured?
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?
Is Your Motor's Propeller Construction Other Than Stainless Steel?


Tell us about any previous watercraft losses that occurred within the last 3 years.
Date of Loss:
Cause of Loss:
Describe Damage to Watercraft and Equipment:
Was anyone injured? Please explain:
Dollar Amount of Damage:



How would you like us to contact you regarding this quote? (You must check at least one method)
Email:        Standard Mail:        Fax:
Fax Number:
How Did You Hear About Us?
Comments:


All quotes provided are valid in Massachusetts only.

Quotes sent in the mail will go to the address provided at the top of this form in the applicant section.  If you'd like us to mail it to a different address, please let us know in the comments box above.

 

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