GENERAL INFORMATION

Please send the quote back by:
 Email Fax Phone Mailed

Name
City or Town
Address (if mailing)
State
DOB
Email Address
Phone
Fax

 

DRIVING RECORD

Drivers License#
Your license number is required to look up your driving record. Driving records determine insurance placement and premiums.

If you wish not to give us your drivers license please list below any violations you may have had in the past 6 years. List them when
and as the following: Minor accidents(under $2,000 damages),
Major Accidents, Moving violations, Speeding and DWI.
TYPE NONE IF YOU HAVE NO VIOLATIONS

BOAT INFORMATION

Please fill in the following the best you can. The more information
the more accurate your quote will be.

If waverunner/Jet Ski please state cc's
MAKE/MODEL
YEAR
LENGTH
H.P.
MAX SPEED
HULL TYPE
NAVIGATION AREA
YRS BOATING EXPERIENCE:

 

COVERAGE SELECTIONS

Unless you are financing the boat all coverage's below are optional. However, some coverage's come as a package. To look up
an explanation of each coverage simply click the "blue"
highlighted title.

Deductible
Higher deductible's offer lower premiums. You may choose more than one deductible
to see the difference in cost. The standard deductible, in most cases is $250- a lower
deductible may increase the premium.

Liability
Liability covers injuries. Liability coverage is listed as total coverage for accident.
Some policy's list a per person maximum and a third amount for property damage.
If so, it will be demonstrated on your quote.

PLEASE NOTE: Some lower liability coverage's are not available in some state's
or with certain agent's. If a quote comes in with higher limits than requested then
those limits are the lowest the agent can provide.

Watercraft Coverage
Type in the value of your boat, motor included. Estimate if necessary

Boat Trailer
 None $1,000 $1,500 $2,000

Medical Payments
 None $1,000 $2,000 $3,000 $5,000

Unattached Equipment
 None $500 $1,000 $2,000

Personal Effects
 None $500 $1,000 $2,000

COVERAGE OPTIONS

Check Options To Include in Quote

Water Ski Liability
Supplemental Towing
Machinery Damage Coverage
 Overland Transportation Coverage
 Uninsured Boater
Depending on the carrier this coverage varies. Check off if you want your quote to
include this coverage.

Created for Carroll K. Steele Insurance Agency, Inc. by