PERSONAL WATERCRAFT QUOTE       

OWNER INFORMATION  

        Watercraft Owner                                
        Date of Birth                                         
        Address                                                 
        City                                                         
        Zip Code                                                
        Phone Number                                      
        Fax Number                                          
        E-Mail Address                                     
        Who Referred You to Our Site?           

        Years PWC Operator Experience      
        Years PWC Ownership Experience  

        Previous Watercraft Operated           

        Previous Watercraft Owned              

- Yes No                                                               Losses in Past (5) Years                          

        Date   

        Amount Paid Out                                 

        Description                                           

WATERCRAFT INFORMATION

Personal Watercraft 1

        Year                                                        
        Make                                                       
        Model                                                      

        Serial Number                                       
        Length                                                    

        CC Size                                                   

        Value                                                      

        Accessories                                           

- 1-Seated 2-Seated 3-Seated 4-Seated 1-Upright                                                       Unit Type                                               

Personal Watercraft 2

        Year                                                        
        Make                                                       
        Model                                                      

        Serial Number                                       
        Length                                                    

        CC Size                                                   

        Value                                                      

        Accessories                                           

- 1-Seated 2-Seated 3-Seated 4-Seated 1-Upright                                                       Unit Type                                               

TRAILER INFORMATION

        Year                                                       

        Make                                                      

        Model                                                     

        Serial Number                                      

        Value                                                     

COVERAGE INFORMATION

- 15/30/10 25/50/25 50/100/50 100/300/100 250/500/100 300 CSL 500 CSL                                                   Liability/Prop. Damage                      

- 15/30/10 25/50/25 50/100/50 100/300/100 250/500/100 300 CSL 500 CSL                                                   Uninsured Watercraft                              

- None 15/30/10 25/50/25 50/100/50 100/300/100 250/500/100 300 CSL 500 CSL                                                   Water-skiing/Towing                           

- None 1,000 2,000 3,000 4,000 5,000 10,000                                                           Medical Payments

PWC1                                

- None 100 250 500 1,000                                                             Comprehensive                                        

- None 100 250 500 1,000                                                             Collision

- No Yes                                                               Towing

PWC2

- None 100 250 500 1,000                                                             Comprehensive  

- None 100 250 500 1,000                                                             Collision                                                      

- No Yes                                                               Towing                                                                       

ADDITIONAL COVERAGES/OPTIONS

Additional Operators

        Name 

        Date of Birth  

        Years Experience

        Name 

        Date of Birth  

        Years Experience

- None Yes No                                                             Additional Insured       

- None Yes No                                                             Loss Payee       

- Yes No                                                               Coverage ever cancelled                                            

MISCELLANEOUS INFORMATION

        Current Insurance Company   
        Expiration Date                           
        Current Premium                        

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