Forms :: Boater's Choice Insurance ::

Boston_Whaler_Owners_Club_Quick_Quote

Fields marked with * are required.

BOAT OWNER INFORMATION
* First Name:
Middle Initial:
* Last Name (or Company Name):
* Telephone (Home):
Telephone (Work):
Telephone (Cell):
* Email Address:
Fax:
* Address:
* City:
* State:
* Zip Code:
Dwelling:
* Date of Birth:
* Marital Status:
* Social Security Number:
Driver's License Number:
* Is this the first boat owned? :
* Years of Boat Ownership:
* Length of most recent boat owned and for how long? :
* Claims or accidents on any boat?:
If YES, please explain (including dates and amounts paid):
Current Insurance Company:
Current Premium:
Expiration date of current policy:
DETAILS OF YOUR BOSTON WHALER
* Boston Whaler Model:
* Year:
* LOA (Length):
Hull ID Number:
* Date of Purchase:
* Previously Untitled?:
* Navigation Area (Hold Ctrl for multiple selections):
* Navigation Limit:
* Type of Use:
If Business or Commercial, please explain:
ENGINE INFORMATION
* Manufacturer:
* Number of Engines:
* Max Horse Power (per engine):
* Fuel Type:
MOORING LOCATION
* Mooring Address:
* Mooring City:
* Mooring State:
* Mooring Zip:
* Mooring County:
INSURANCE COVERAGE REQUESTED
* Hull & Machinery Value (Boat and Motor combined):
Trailer Value (if applicable):
Dinghy/Tender Value (if applicable):
* Liability Limit:
* Deductible:
* Personal Effects:
* Will Vessel Need Lay Up?:
* Length of Lay Up (months):
* Towing:
* Has boat insurance been cancelled or non-renewed in last 5 years?:
If Yes, please provide details:
* How Did You Hear About Us? :
Lienholder Information (including address):
Notes to Underwriter:	This can be used for boating experience information or specific navigation requests.
DEALER INFORMATION (if applicable)
Dealership Name:
Dealership Address:
Dealer City, State, Zip:
Dealer Phone #: