Applicant Information

Name: *

Date of Birth: *

How did you hear about us? *

Address:

City, State, Zip:

Home Phone:

Work Phone:

Email: *

Personal Watercraft Information

Year *   Manufacturer *  Model *

Length (not to exceed 18') *   ft.   in.   # of Engines:

Engine #1: *

CCs

Engine #2:

CCs

Trailer:

Year    Make    $ Purch. Price

Total Number of Owners: *

Purchase Date: *

Total Purchase Price: *

State where vessel is kept. *    Zip: *

Operator's Experience (All Household Residents over 15 and other Operators)

Operator #1:

Name: *   DOB: *

Driver's License #: *   State Issuing License: *

Operator #2:

Name:    DOB:

Driver's License #:    State Issuing License:

Operator #3:

Name:    DOB:

Driver's License #:    State Issuing License:

Violation/Loss History (applies to ALL operators):

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

Coverage Desired

Standard Package Includes "All Risks" Physical Damage on Personal Watercraft, $250 Deductible, $15,000 Liability, $1,000 Medical Payments

Optional "Hull" Deductible:
$300   $350   $500   No, thanks

Increased Liability for "Package":
$25,000   $50,000   $100,000   $300,000   No, thanks

Increased Medical Payments for "Package":
$2,500   $5,000   No, thanks

Liability ONLY Coverage:
$15,000   $25,000   $50,000   $100,000   $300,000   No, thanks

Medical Payments with "Liability Only" Coverage:
$1,000   $2,500   $5,000

Optional Coverage Desired (not available with "Liability Only" Coverage):

Watersports Liability Coverage: (Cannot exceed liability limits chosen above)
$15,000   $25,000   $50,000   $100,000

Uninsured Boatowners Coverage: (Cannot exceed liability limits chosen above)
$15,000   $25,000   $50,000   $100,000

Trailer Coverage (Trailer Deductible Applies)

Accessories/Custom Paint Coverage (Descriptions & Values Listed Below)

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: