Boat Insurance Fact Finder Date Date Format: MM slash DD slash YYYY Prepared By:*Alonso, FrancescaAldana, SerigoBalco, CraigBlue, TiffanyD’Hondt, MichaelDiaz, LisaDreday, BabsDugan, LeeAnnGodwin, DavidHill, CaitlinHilliard, SherrinJennings, MatthewKennedy, BrewaLamb, KaylaLevi, DouglasLong, TinaLuciano, CarmenLynch, BrookeMella, TonyMitrano, SandraMyers, TamaraNazario, JimmyPeshak, BriannaPirko, PhyllisRhoads, DanRuss, MichaelSalvator, MatthewSaroukos, AnthonySchrack, LeslieShepard, NikkiWilliams-Lewis, NicoleWoods, DarrylYoung, AmyClient Name: How did you hear about our office?Phone:Email Address:* Preferred Method of ContactPhoneEmailTextAddress: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do You:OwnRentCurrent Insurance Carrier: Renewal Date: Date Format: MM slash DD slash YYYY Years With: Premium $: Other than price what is most important to you? Or Between Price, Protection & Svc what is most important?Driver InformationDOB Date Format: MM slash DD slash YYYY Marital Status: FemaleMaleDriver's License #: State: Years Boat ExperienceTickets, accidents, suspensions, or claims w/ the last 5 years?YesNoDetailsDriver 2 (If Necessary)Name: DOB Date Format: MM slash DD slash YYYY FemaleMaleRelation: Marital Status: Driver's License #: State: Tickets, accidents, suspensions, or claims w/ the last 5 years?YesNoDetailsOthers in the household of driving age? Boat InformationYear: Make: Model: Market ValueTypeInboardOutboardBothJetHull MaterialNumber of motorsTotal HorsepowerMax SpeedCoverage for trailerUsePleasureBusinessWhere is it StorageBoat / Jetski InformationYear: Make: Model: Market ValueTypeInboardOutboardBothJetHull MaterialNumber of motorsTotal HorsepowerMax SpeedCoverage for trailerUsePleasureBusinessWhere is it StorageOne Way Miles: Days/Week: Annual Miles: Current / Desired Limits... (Or Copy of Current Declarations Page)BI:PD:Comp:Coll:UM:Med Pay:On water towing:Fishing Equipment ($):PhoneThis field is for validation purposes and should be left unchanged.
