Vessel Information

JetSki/PWC #1:

JetSki/PWC #2 (if necessary)

Year*

Manufacturer*

Model*

Watercraft Type*
RunaboutBass JetSki/PWCCabin CruiserPantoonSailJetSki/PWC-Single-HullSailJetSki/PWC-Multi-HullHouseJetSki/PWCInflatableN/A

Length *

JetSki/PWC Use?*
Pleasure useRacing/Speed contestsBusiness/Commercial useRented or Leased to othersResidenceN/A

Market Value*

Number of Engines *
01234+N/A

Total Horsepower *

Engine Type *
OutboardInboardStern Drive(I/O)Waterjet PumpOtherN/A

Deductible *
$500$1000OtherNo CoverageN/A

Hull Material *
Fiber GlassAluminiumRigid Hull InflatableInflatableRopleneWoodSteelN/A

Trailer Coverage *
$1,000$2,000$3,000$4,000$5,000$7,500$10,000+N/A

Storage Location *
HomeMarinaStorage FacilityN/A

Does your JetSki/PWC or engine have any structural modifications or performance customization? *
YesNoN/A

Year(B2)

Manufact(B2)

Model(B2)

Watercraft Type(B2)
RunaboutBass JetSki/PWCCabin CruiserPantoonSailJetSki/PWC-Single-HullSailJetSki/PWC-Multi-HullHouseJetSki/PWCInflatableN/A

Length(B2)

JetSki/PWC Use?(B2)
Pleasure useRacing/Speed contestsBusiness/Commercial useRented or Leased to othersResidenceN/A

Market Value(B2)

Number of Engines(B2)
01234+N/A

Total HP(B2)

Engine Type(B2)
OutboardInboardStern Drive(I/O)Waterjet PumpOtherN/A

Deductible(B2)
$500$1000OtherNo CoverageN/A

Hull Material(B2)
Fiber GlassAluminiumRigid Hull InflatableInflatableRopleneWoodSteelN/A

Trailer Coverage(B2)
$1,000$2,000$3,000$4,000$5,000$7,500$10,000+N/A

Storage Location(B2)
HomeMarinaStorage FacilityN/A

Operator Information

Primary Operator Name

Operator 2 Name #2 (if necessary)

Primary Operator Name *

Gender*
MaleFemaleN/A

Married*
YesNoN/A

Date of Birth *?*

Accidents/Tickets in the past 3 years

O2 Name(if necessary)

Gender(O2)
MaleFemaleN/A

Married(O2)
YesNoN/A

Date of Birth (O2)

Accidents/Tickets in the past 3 years02

Additional Information

First Name

Middle Initial

Last Name

Address

Address L2

City

State

Zip Code

Country

Email

Phone Number

Current or Prior Insurance Company*

Continuous Cover.
3+ Year2 Years1 Year12 Months6 MonthsUnder 6 MonthsNot Currently InsuredN/A

Policy Expires In
Not SureA few days2 weeks1 month2 months3 months3-6 months6+ monthsN/A

Claims in 3 Years
None1234+N/A

Tickets in 3 Years
None123456+N/A

Coverage Desired
Standard CoveragePremium CoverageState MinimumN/A

Message

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