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1
Demographic Information
2
Boat Details
3
Covereges
Name
*
First
Last
Phone
*
Email
*
Address
*
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Next
Uninsured/ Deductible keep
Hull ID Number
*
Year
-- Select Year --
Make
Model
Watercraft Market Value
Is Boat/PWC kept at your residence?
Yes
No
Where do you keep it at home?
Parking Lot
Lift
In-Water
Yard
Driveway
Garage
Other
Where do you keep it?
Where is Boat/PWC kept during boating season?
Storage Building
Storage Yard
Rack Storage
Lift
In-water
Others
Original Owner
*
--- Select Choice ---
Yes
No
Previous
Next
Covereges
--- Select Choice ---
Full Coverege
Liability
Comprehensive Deductible
$250
$500
$750
$1,000
$1,500
$2,000
Collision Deductible
$250
$500
$750
$1,000
$1,500
$2,000
Do you need extra covereges?
--- Select Choice ---
Yes
No
Bodily Injury & Property Damage
--- Select Choice ---
30/60/25
50/100/25
100/300/25
100/300/50
250/500/25
250/500/50
Uninsured/ Underinsured Motorist Body Damage
--- Select Choice ---
None
30/60
Uninsured/ Underinsured Property Damage
--- Select Choice ---
None
25 W/$250 Ded
Personal Injury Protection
--- Select Choice ---
None
$2,500
$5,000
$10,000
Any Additional Request
SR22, any other coverage etc.
Previous
Submit
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