Products - Bristol Gold Watercraft Insurance Policy

Boat quote submission form.

Applicant Information

Name: *

Date of Birth: *

How did you hear about us? *

Address:

City, State, Zip:

Home Phone:

Work Phone:

Email: *

Are you a fishing guide? *

Yes No

Watercraft Information

Year * Manufacturer * Model *

Length * ft. in. Beam:

Hull Material:

Fiberglass Aluminum Wood

Type: *

Bassboat Runabout Pontoon Deckboat Walleye
Other* (details)

* If Other please explain:

Engine #1: *

Make * Model * Year * HP *

Engine #2:

Make Model Year HP

Type: *

Outboard Inboard I/O Water Jet None

Trailer: *

Year * Make *

Trolling Motor:

Lbs. of Thrust Make Model Year

Equipment:

Depth/Fish Finder Stainless Prop GPS

Anti Theft Trailer Anti Theft Boat Anti Theft Prop

VHF Radio Vapor Detector Auto Halon/CO2

Purchase Date: *

Total Purchase Price: *

Operator's Experience

Total years of boat ownership: * Total years of operating experience: *

Licenses Held:

Previously owned boats:

Make Model HP Years Owned

Make Model HP Years Owned

Make Model HP Years Owned

Boating Courses Completed & Year:

Any Auto or Watercraft Losses? * Yes No

If yes:
Date Circumstances $ Amt. Paid

Date Circumstances $ Amt. Paid

Date Circumstances $ Amt. Paid

Any Auto or Watercraft Violations or Suspensions? * Yes No

If yes:
Date Circumstances

Date Circumstances

Date Circumstances

Intended Use

Waters Navigated: *

Inland Great Lakes Coastal Chesapeake Bay ONLY
Other* (details)

If Other please explain:

State where vessel is kept. * Zip: *

Coverage Desired

Hull & Equipment:

$

O/B Motor #1:

$

O/B Motor #2:

$

Trailer:

$

Trolling Motor:

$

Personal Effects:

$ ($1000 included)

Watercraft Liability: *

$50,000 $100,000 $300,000 $500,000

Deductible: *

$100 $250 (standard) $500 $1000

Choose only one (1): *

Disappearing Deductible OR 10% Annual "Claims-Free Discount" At Renewal

Optional Coverage

Bristol Gold Plus What's this?
Contaminate/Fuel Spill Coverage What's this?
NAVIGUARD™ MBI What's this?
Total Replacement Cost Coverage What's this?
{watercraft may only be five (5) model years old or newer!}

Current Insurance

Issuing Company:

Exp. Date:

Current/Renewal Premium:

$

Has vessel been continuously insured for the past 12 months? Yes No

If "No" please explain: