Personal Lines Watercraft
Submission Form

*Marks Required Fields
Insured
Name:
Address:
City  State  Zip Code 
Social Security #:
Agency Name:
Agency Contact:
Telephone:  Fax:  Email: 
Marital Status: Married Single
Date of Birth:  Years of Boat Ownership: 
Hull Information
Year:  Length:  Make:  Model: 
Hull ID, if available:
Watercraft Type (choose one)
Bass Boat
Powerboat
Sailboat
House Boat
Power Boat/Multi-Hull
Sailboat Multi-Hull
Jet Boat
Pontoon/Deck
Ski Boat
Manuel
Yacht
Motor
Year:  H.P.:  Make:  Model: 
(Motor Model not required for liability only quote)
Engine Type (choose one)
Outboard
Inboard/Outboard
Inboard
Jet Drive
O/B Jet
Sailboat
Manuel (no motor)
Fuel (choose those applicable)
Gas  Diesel  Electric  No Motor
Value
Hull:  Motors:  (I/B & I/O, add to hull value)
(Include trolling motors)
Mooring/Storage Location
State  County  Zip Code 
Boat Operated (check all that apply)
Lakes
Rivers
Ozarks
Indicate Requested Limits for desired Coverages. (If requested limits are not available, we will quote as close as possible.)
Liability:
Uninsured Boat Owner  Med Pay 
Hull & Motor Coverage  Deductible 
Personal Effects  Towing  Trailer 
Machinery Depreciation Waiver: Yes No
List all tickets and accidents incurred in the last 5 years by any operator that will be listed on the application.
Are there any tickets or violations?: Yes No
If yes, list name, date and details below:
List all boating accidents/claims incurred in the last 5 years by any operator that will be listed on the application.
Are there any accidents or claim: Yes No
If yes, list name, date and details below:
Is there a certificate of completion for any boating safety course?: Yes No
If yes, list which course:
(A copy of the certificate would need to be submitted with the application to receive the credit.)

This is only a quote. The risk is subject to the underwriting approval of the application. For coverage to begin as requested, the application must be fully completed, signed and postmarked within 72 hours of the requested effective date, otherwise coverage is bound 12:01 a.m. the day following postmark.