Boat or Personal Watercraft Quote Form
Please
fill out as much information as possible. If you have any questions
about this form or filing a claim, please contact
us.
|
| PERSONAL
INFORMATION |
| Name: |
|
| Street
Address: |
|
| City,
State, Zip Code: |
|
| Preferred
method of contact: |
|
|
E-mail: |
|
|
Telephone: |
|
|
Fax: |
|
| |
|
| BUSINESS
INFORMATION |
| Boat/Yacht
Personal Watercraft |
| Year:
|
Make: |
Model:
|
|
|
| Max.
Speed:
|
Total
HP:
|
#
of Motors:
|
|
|
|
Inboard/Outboard
Outboard
Jetdrive |
| |
|
| DRIVER INFORMATION |
| Name:
|
DOB:
DL
#:
|
| Name:
|
DOB:
DL
#:
|
| Name:
|
DOB:
DL
#:
|
| Have
any of the above drivers had any tickets or accidents in the last
three years?
Yes
No |
| If
yes, please
list all tickets and/or accidents in the last three years, including
dates: |
|
| Liability: |
|
| Medical
Payments: |
|
| Deductible: |
|
| Value
of Boat & Motor(s): |
|
| Value
of Trailer: |
|
| |
|
| UMBRELLA
POLICY (OPTIONAL) |
| Are
you interested in a Umbrella Policy?
Yes
No |
| If
yes, complete the following: |
|
| #
of cars: |
|
| #
of boats: |
|
| #
of houses: |
|
| #
of drivers in the household: |
|
| Umbrella
Limit: |
|
| |
|
|
|
|
| Submitting an insurance quotation request
to Alexander & Strunk Insurance does not constitute a binding confirmation
of new or altered insurance coverage. Verbal and/or written confirmation
must be obtained from Alexander & Strunk Insurance to confirm binding or altering
coverage. |
