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Watercraft Insurance Form
Are you the referral source or agent filling out this form on behalf of the Insured?
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Select
Yes
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Agent Name
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Agent Phone
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Agent Email
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Personal Information
First Name
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Last Name
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Date of Birth
City
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Email
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
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Hawaii
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Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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New Hampshire
New Jersey
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New York
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Phone
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Zip Code
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Address
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Insurance Information
Boating liability
Select
No Coverage
Split limits
Combined Single Limits
Bodily injury & property damage- per person/per accidentÂ
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$50,000/ $100,000
$100,000/$300,000
$250,000/$500,000
$500,000/$500,000
Medical Payments
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No Coverage
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
Uninsured Boater Coverage
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Yes
No
Boat Safety Course?
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Yes
No
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Boat Information
Currently Insured?
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Yes
No
Boat Year
Hull Type
Engine Type
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Inboard
Outboard
Sterndrive
Water Jet
Manufacturer
Hull length
Hull Material
Total Horsepower
Usage
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Personal
Charter
Rental
Value
Number of Engines
Trailer Coverage
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Yes
No
Additional Notes
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This is a staging environment
