PERSONAL WATERCRAFT WORKSHEET

 

First Name:

Last Name:

Garaging Address:

Garaging City:

Garaging State:

California

Garaging Zip Code:

Phone Number:

Fax Number:

E-Mail Address: 

 

MAILING ADDRESS (OPTIONAL)

 

Mailing Address
If Different from Garaging:

 

Mailing City:

Mailing State:

Mailing Zip Code:

 

DRIVER INFORMATION

 

 

Driver One

Driver Two

Driver Three

Driver Four

First Name

Birthdate

Sex

Marital Status

State Licensed

Yrs Boating
Experience

Occupation

WATERCRAFT INFORMATION

 

 

Boat

Trailer

Motor

Year

Make

Model

Type (ie; JetSki,
Jet Drive Boat)?

Identification
Serial Number

Cost New Value

Hours Used
Each Year

Horsepower CC or
Motor Size

Boat Length

ft.

Ownership

VIOLATION INFORMATION

 

Last 3 Yrs (Minors)
Last 5 Yrs (Majors)

Driver 1

Driver 2

Driver 3

Driver 4

Minor Violations - Speeding,
Turn, Stop Sign, Red Light, etc.

Accidents - Non Chargeable

Accidents - Chargeable

Major Violations - Drunk Driving,
Reckless, Hit & Run, etc.

COVERAGE INFORMATION

 

 

Bodily Injury

Property Damage

Personal Liability

Uninsured Motorist

Medical Payment:

 

DEDUCTIBLE INFORMATION

 

 

Boat & Motor

Trailer

Comprehensive (Theft)

Collision

MISC INFORMATION

 

Current Insurance Company:

 

Expiration Date:

Current Premium $:

Questions or Comments
to help the Agent: 

 

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Thank you for your interest.