Office  Hours: M-F  9am to 5pm
670 E 32nd St. Suite 12
  Yuma, AZ   85365    
Call today: (928) 317 1212
          Boat and Watercraft Quoting Information

              Please provide as much information as possible within the application below for the most accurate quotes available.
             Upon completion of this information, hit "submit" once and the form will be sent to a representative for quoting. The information provided will be quoted among the multiple insurance carriers our office proudly represents. A representative will respond with the quotes via the contact option selected, normally in 1 business day or less.

                 Thank you for your time and we look forward to assisting you!


      Cabin Cruiser







 
















Personal Watercraft











 

 

  


          Sail Boat







 

 

 

  

 

  

 Personal Watercraft

 

 

 

 








         Runabout






 
Primary Insureds Information

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
State:
Zip Code: (5 digits)
Mailing Address:
Phone # 1:
Phone # 2:
E-mail:
Preferred Contact:
Date of Birth:
Drivers License Status:
Drivers Licensed Issued in...:
Marital Status:

Other Household Members/Operators
Please list all household members of driving age. Select if this person will be listed as a "Rated Driver" or if they will be "Excluded" from coverage.
Household Member/Operator     
 #2- First Name:
        Last Name:
Relationship to Primary Insured:
Household Member/Operator     
 #3- First Name:
        Last Name:
Relationship to Primary Insured:
Are there any other household operators to list?:
Will any of the Household Members be Excluded from Coverage?:

Motor Vehicle Report/History
Has a listed driver had a suspended license in the past 5 yrs?:
Is an SR-22 needed for any listed driver?:
*SR-22 for what State:
Any driver with accidents or violations in the past 3 years?:
*Please select incident from list- Incident # 1:
Next driver with accident or violation in the past 3 years?:
Incident # 2:
Next driver with accident or violation in the past 3 years?:
Incident # 3:
Comments:
I authorize verification of my Motor Vehicle and credit history:

Coverage Information
Select All Requested Coverages For Quoting.
Liability Limits:
Uninsured and Underinsured Boaters Coverage:
Medical Payments:
Comprehensive Deductible:
Collision Deductible:
Roadside Assistance:
Emergency Towing (on water):
Personal Property or Fishing Equipment Value:
Trailer Coverage:

Boat/Watercraft # 1 Information
Select type of craft:
Hull Identification Number (Serial #)
( if available ):


Or Enter Boat Specifications-
Year:
Make:
Model:
Length of Boat:
Seats how many people:
Type of Engine/Propulsion:
Type of Hull:

Discount Questions ( if applicable )
Current/Previous Insurance Coverage Information:
Current/Previous Insurance Carrier
  ( if applicable ):
Do you have any other policies with the listed carriers?:
Residency Status: