On-Line Boat & Jet Ski Insurance Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal Data Your Name: Street Address: City: State: (Must be New York) Zip Code: E-Mail (REQUIRED): E-Mail again for accuracy: Phone: Fax (optional): Primary Insured's Occupation:   Marital Status: Single Married Homeowner? Yes No   Boat Currently Insured? (If yes, list carrier, and # of years continuous. If none, type N/C)   Is this Boat Co-owned? (If yes, list all owners names) OPERATOR INFORMATION #1 Name: Birthdate: Sex (M/F): # Years U.S.  Licensing: Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below: Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years: Number & Type of MAJOR violations last 3 years: Number of Years Boating Experience: OPERATOR INFORMATION #2 (if none, leave blank) Name: Birthdate: Sex: # Years U.S.  Licensing: Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below: Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years: Number & Type of MAJOR violations last 3 years: Number of Years Boating Experience: VESSEL & UNDERWRITING INFORMATION Year of Boat: Make & Model (be specific):   Boat Length: Hull Type (wood, Metal, fiberglass, etc):   Max. Speed (in MPH): Market Value: $   Engine Make: Engine Type: (Inboard, I/O, Jet)   Engine Horse Power: Fuel Type: (Gas, Diesel, etc.)   Trailer Cov. Needed? Yes No Yr./Make/Model of Trailer:   Trailer Value: $ Where is boat moored or stored?   Describe waters boat taken on? Describe boat general usage? (fishing, ski, etc.) VESSEL COVERAGES: Limits of Liability: $15/30 BI / 10 PD $25/50 BI / 15 PD $50/100 BI / 25 PD $100/300 BI / 50 PD $250/500 BI / 100 PD   Hull Coverage: NO Coverage $250 Deductible $500 Deductible $1000 Deductible   Water Ski Medical Coverage? Yes No   Uninsured   Motorists Cov.? Yes No   Comments or Remarks: (List additional drivers, special coverages, etc. here) Send my quotation via: E-Mail Fax Regular Mail Call me by Phone! Thank you for filling out this form COMPLETELY! We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. Yes, I Agree. Please Send Me a Boat Quote NOW! Click Button Below When Done Please Click Only Once . . . May take up to 30 seconds!