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Boat Quote Sheet

YOUR PERSONAL DATA:

           
  Name :      
         
  Street Address : Date of Birth :  
           
  City : Country :  
           
  State: (Must be Ohio) : Zip Code :  
           
  Drivers License : Date of Birth :  
           
  Tickets/Accidents : Sr-22 filing :  
           
  E-Mail (REQUIRED) : Social Security :  
           
  Phone : - Occupation :  
           
  Married/Single :    
     
  Rent/Own Home_Currently Insured? :  
     
  Boat Insurance YES NO Insured With? :  
     
  HowLong :    
     
  VESSEL & UNDERWRITING INFORMATION    
  Year of Boat : Make & Model
(be specific)
:  
         
  Boat Length : Hull Type
(wood, Metal, fiberglass, etc)
:  
           
  Max. Speed (in MPH) : Market Value :  
           
  Engine Make : Engine Type: (Inboard, I/O, Jet) :  
           
  Engine Horse Power : Fuel Type: (Gas, Diesel, etc.) :  
           
  Trailer Cov. Needed? : Yr./Make/Model of Trailer :  
           
  Describe waters boat taken on? : Describe boat general usage? (fishing, ski, etc.) :  
     
  VESSEL COVERAGES      
 

Limits of Liability :

     
  $15/30 BI / 10 PD $25/50 BI / 15 PD
$15/30 BI / 10 PD $25/50 BI / 15 PD
$15/30 BI / 10 PD
     
 

Hull Coverage :

     
  NO Coverage     $250 Deductible
$500 Deductible $1000 Deductible
     
           
  Water Ski Medical Coverage? : Yes  No Uninsured Motorists Cov.? : Yes   No  
     
     

 

         
   
         

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