Quotes

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”)

Boat Year
201920182017201620152014201320122010200920082007200620052004200320022001

Boat Make

Boat Model

Length of Boat ft’

Value of Boat (include value of motor)

Motor Year
2019201920172016201520142013201220112010200920082007200620052004200320022001

Motor Make

Motor Model

Horsepower

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

Do you want to insure the boat against physical damage?
yesno

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)

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

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:______ Collision:_______
$250 deductible$500 deductible$1,000 deductible $100 deductible$250 deductible$500 deductible$1,000 deductible

Roadside/Trip Interruption?
yesno

Remarks (if any):