Personal (PWC) watercraft/Jetboat insurance quotation request

Coverage may not be available in all areas.

Basic information 

Registered owner
Address line 1
Address line 2
City, State/Province
Zip/Postal code
Country
eMail
Telephone-Business
Telephone-Home
Telephone-other
Fax/telecopier
* We need at least one contact telephone number in case we need to clarify an answer.
PWC/Jetboat information All information below is required
PWC/Jetboat Make & model
PWC/Jetboat model year
Total HP, KW or CC's
Number of engines
Top speed in mph   
Jetboat length
Where will you mainly use your PWC/Jetboat in the next 12 months?
Where will you keep your PWC when not in use?
Stored inside

In the next 12 months
Will your PWC be laid-up?          If No Tab to next section
If Yes show dates  
If Yes where will be laid-up?
Stored inside

Coverages requested (if coverage not required enter "0")
PWC/Jetboat coverage amount
Trailer coverage amount   Please provide details
Liability amount  

Operator(s) information
# Name Date of birth/age Driver's license # & state
1
2
3
4

Years experience

 In the last four years Driving
as a PWC/Jetboat operator Tickets Accidents

Occupation
1
2
3
4
Prior PWC/Jetboat losses
Please indicate the type of PWC/Jetboat loss(es) you have had. (Select all applicable) No losses

Theft

Over the road

Hit submerged object

Injury

Other (provide details)

Please provide details for "Yes" replies

If you have a trailer, in Remarks tell us the year, make, model and number of axles.

Remarks/comments:

Please add your comments here to elaborate on information provided to tell us more about your situation or coverage options you require.

Important note: Please review entire submission carefully before submitting this form as false information may void your insurance. Submitting this form does not bind you to purchase the insurance or any Insurer to accept the risk, however it is agreed that the information submitted shall be the basis of the quotation and contract should coverage be bound and/or a policy issued. No coverage is bound or in force until confirmed in writing by our office. The information collected from you is used to underwrite coverage and services. This information will be provided to others.  I have read the Important Information and understand and agree with the contents thereof.