Step 1 of 5 20% Contact InformationFirst Name* Last Name* Email* Home Phone*Cell PhonePreferred Contact MethodSelect contact methodPhoneEmailNo PreferenceBest Time to ContactMorningAfternoonEveningAnytimeHow did you find us?Passport AmericaEscapeesFMCAMagazineInternetYellow PagesAgentDealerManufacturerFriendRelativeOtherWere you referred by an Agent, Dealer, or Manufacturer? Yes No Company Name Phone Number Email Address Promotional Code Driver 1 - Insurance InformationFirst Name* Last Name* Birth Date* MM slash DD slash YYYY Martial Status*MarriedSingleGender* Male Female Years of Boating Experience* Relationship*ChildCo-HabitantInsuredParentSpouseOtherPrimary Residence*Full Time RVerOwn Home/CondoLive with ParentsOwn Home/CondoOwn Mobile HomeRentOtherPast 3 yearsNumber of at fault accidents* 0 1 2 3 4 or more Number of not at fault accidents* 0 1 2 3 4 or more Number of traffic violations* 0 1 2 3 4 or more Do you need to add a second driver? Yes No Driver 2 - Insurance InformationFirst Name* Last Name* Birth Date* MM slash DD slash YYYY Martial Status*MarriedSingleGender* Male Female Years of Boating Experience* Relationship*ChildCo-HabitantInsuredParentSpouseOtherPrimary Residence*Full Time RVerOwn Home/CondoLive with ParentsOwn Home/CondoOwn Mobile HomeRentOtherPast 3 yearsNumber of at fault accidents* 0 1 2 3 4 or more Number of not at fault accidents* 0 1 2 3 4 or more Number of traffic violations* 0 1 2 3 4 or more Mailing Address* Street Address City State Zip Code Mooring/Storage Address (if different than mailing) Street Address City State Zip Code Registration Address (if different than mailing) Street Address City State Zip Code Unit 1 - Unit InformationUnit Type*AirboatBassCabin CruiserCatamaranCenter ConsoleDinghyFishing BoatHigh PerformanceHouse BoatJet BoatPersonal WatercraftPontoonRunaboutSailboatYachtOtherPlease specify other Model Year Make* Model* # of Motors Total Horsepower/CC Propulsion TypeInboardInboard/OutboardJetOutboardSailOtherLength Current Value Purchase Price Purchase Date MM slash DD slash YYYY Do you need to add a second unit? Yes No Unit 2 - Unit InformationSecond Unit Type*AirboatBassCabin CruiserCatamaranCenter ConsoleDinghyFishing BoatHigh PerformanceHouse BoatJet BoatPersonal WatercraftPontoonRunaboutSailboatYachtOtherPlease specify other Model Year Make* Model* # of Motors Total Horsepower/CC Propulsion TypeInboardInboard/OutboardJetOutboardSailOtherLength Current Value Purchase Price Purchase Date MM slash DD slash YYYY Current InsuranceInsurance Carrier Current Premium Expiration Date MM slash DD slash YYYY Current Limits of Bodily Injury Liability Coverage OptionsPlease Note: Liability Coverage will be included for all motorized vehiclesComprehensive Deductible25050010001%2%3%Collision Deductible25050010001%2%3%On Water Towing Include Exclude Boat Trailer Fishing Equipment Special NeedsPlease include any special coverage options you require or notes regarding your request:
