"Insure Today - Be Sure Tomorrow"
Menu ▾
Home
Products & Client Services
Our Companies
Claims & Payments
Contact Us
Boat / Yacht / Personal Watercraft Quote
GENERAL INFORMATION
Note- Coverage can not be bound or altered by this submission
First name
*
Last name
*
Address
Address 2
City
State
Zip
Daytime telephone number
Alternate telephone number
Email address
*
DRIVER INFORMATION
Primary Driver
Secondary Driver
Name
Sex
Male
Female
Male
Female
Date of Birth
Yrs. Licensed to Drive Boat
Less than 1
1
2
3
4
5
More than 5
Less than 1
1
2
3
4
5
More than 5
License Number
State Licensed
NJ
other
NJ
other
Married
No
Yes
No
Yes
Coast Guard Safety Course
No
Yes
No
Yes
At Fault Accidents *
0
1
2
3
4
More than 4
0
1
2
3
4
More than 4
Number of Motor Vehicle Points *
0
1
2
3
4
5
6
7
8
9
More than 9
0
1
2
3
4
5
6
7
8
9
More than 9
Number of Boating Incidents *
0
1
2
3
4
5
6
7
8
9
More than 9
0
1
2
3
4
5
6
7
8
9
More than 9
Driver's License Number
Any DWI's
No
Yes
No
Yes
* In The Past 3 Years
BOAT INFORMATION
Year
Manufacturer
Model
Length
Hull ID Number
Hull Material
Fiber
Aluminum
Wood
Fiber over wood
Steel
Composite
Other
Total horsepower (all engines)
Protective Devices
None
Automatic Fire Extinguisher
Alarm High Water/Fire/Theft
Central Station Monitor
No Strike Lightning System
Home Made?
No
Yes
Used for Racing
No
Yes
OUTBOARD MOTOR INFORMATION
Number of motors
1
2
Motor #1
Motor #2
Horsepower
Type of Fuel
Gas
Electric
Gas
Electric
VALUES TO INSURE
If coverage desired, enter Hull Value
If coverage desired, enter Motor #1 Value
If coverage desired, enter Motor #2 Value
If coverage desired, enter Trailer Value
CURRENTLY INSURED
Company Name:
Policy Number:
Policy Expiration:
New Purchase:
Yes
No
Ever Cancelled:
Yes
No
COMMENTS
Disclaimer
I understand that my coverage (or changes in coverage)
ARE NOT
binding via this on-line request; Changes
ARE
considered binding when I receive an email (or fax) response from my agent indicating that they have received my request.
I have read and agree with the disclaimer.
(Box must be checked before request can be sent)
