Quotes

Name of Proposed Insured

Phone Number

Email

Applicant’s Date of Birth

Applicant’s Gender
malefemale

Type of Life Insurance
term lifewhole life

Select Term Length
10 year15 year20 year25 year30 year

Amount of Insurance Requested

Applicant’s Height

Applicant’s Weight

List any medical conditions, family history, or medications currently taken.

Full Name

Address

Phone Number

Email Address

Boat Type
speed boatfishing boatpontoon boatother

Hull Type
fiberglassaluminumother

Hull ID No.

Registration No. (if already registered)
(begins with “IN####XX”)

Date of purchase

Boat Year
202120202019201820172016201520142013201220102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985

Boat Make

Boat Model

Length of Boat ft’

Value of Boat (include value of motor)

Motor Year
2021202020192019201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985

Motor Make

Motor Model

Horsepower

Top Speed

Coverage Options (Liability to Others)
Bodily Injury(per person) / Bodily Injury (per accident) / Property Damage (per accident)
$100,000/$300,000/$100,000$250,000/$500,000/$100,000$300,000 Combined Limit$500,000 Combined Limit

Medical Payments (for you and passengers)
$5,000 per person$10,000 per person

Did you finance this purchase?
yesno

Do you want to insure the boat against physical damage?
yesno-just liability to others

On-Water Towing?
yesno

Do you want to insure the trailer against physical damage?
(deductibles selected on boat will also apply to trailer)
yesno

Boat Storage Zip Code

Remarks (if any)

Full Name

Address

Phone Number

Date of birth

Email Address

Motorcycle Year

Motorcycle Make

Motorcycle Model

Motorcycle VIN

Engine Capacity (cc’s)

Current Value of Motorcycle

Vehicle Use
PleasureCommute (to & from work)Off-road useOther

Annual Miles Ridden

Do you have motorcycle endorsement on license?
yesno

Coverage Options (Liability to Others)
Bodily Injury(per person) / Bodily Injury (per accident) / Property Damage (per accident)
$100,000/$300,000/$50,000$250,000/$500,000/$100,000$300 CSL$500 CSL

Medical Payments (for you and passengers)
$5,000 per person$10,000 per person$25,000 per person

Physical Damage to Motorcycle
Comprehensive
none-liability only$250 deductible$500 deductible$1,000 deductible

Roadside/Trip Interruption?
yesno

Modified frame, nitro oxide, turbo or supercharger?
yesno

Anti-lock brakes?
yesno

Lo-jack device installed?
yesno

How many years of riding experience do you have?

Have you completed an approved safety course?
yesno

How often do you ride during season?
1-3 days/month1-2 days/week3-4 days/week5-7 days/week

How much accessory coverage do you need?
(base policy generally covers up to $3,000)

Remarks (if any):

Full Name

Address

Phone Number

Email Address

Travel Trailer Year
202120202019201820172016201520142013201220102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985

Travel Trailer Make

Travel Trailer Model

Travel Trailer VIN (17 characters)

Body Style (length & number of slides)
18'19'19' 1 slide20' 1 slide22' 1 slide23' 1 slide24' 1 slide25'25' 1 slide26' 1 slide27' 1 slide28' 1 slide28' 2 slides29' 1 slide29' 2 slides30' 1 slide30' 2 slides31' 1 slide32' 1 slide33' 1 slide34' 2 slides

How is travel trailer towed?
bumper hitchbed hitch

Date of purchase

Are you the original owner?
noyes

Current value of travel trailer

Garaging Zip Code

Is travel trailer parked at a single location year round?
noyes

Is the travel trailer a rented vehicle, ever rented to others, or used for business?
noyes

Is the travel trailer taken to/from work or used at a work location?
noyes

Primary vehicle use
recreationprimary residence

What is the approximate number of days used per year?

Is the travel trailer financed?
noyes

Years of experience operating a travel trailer (in years. Enter 0 if none)

Liability coverage is extended from the towing vehicle.
Are you interested in covering the travel trailer against physical damage?
noyes

Additional vacation liability (includes $10,000)
noyes

Personal Effects (round to nearest thousand dollars. Enter ‘0’ if none)

Roadside Coverage
noyes

Remarks (if any)