Watercraft Questionnaire Full Name (First, MI, Last) Phone Number Email Address Home Address (Also Prior if < 60 days) Please provide the following information for EACH DRIVER of the watercraft: Name Date of Birth Marital Status Driver's License Number Accidents, Tickets, Claims & Violations in 5 years Years of boating experience Safety Course Completed (Type & Date) Boat/Motor/Trailer Information: Boat Year, Make & Model Boat Type (fish, sail, speed, etc) Hull Material Length Boat Value (Does this value include the motor?) (Is this the current Market Value OR the Purchase Value including tax & title fees?) Motor Type —Please choose an option—InboardOutboardIn/Out Motor Year, Make & Model Motor Value (if not included boat value) Horsepower Maximum Speed Enhanced Performance Modifications Additional motors Trailer Year, Make & Model Trailer Value Value of Boating Accessories (depth finder, fish finder, trolling motor, etc) Value of Boating Equipment (skis, tubes, etc) Value of Fishing Equipment Year you purchased the boat (Original Owner?) Where is the boat kept during boating season? —Please choose an option—Parking LotLiftIn WaterYardDrivewayGarageOther Where is the boat stored during the off season? —Please choose an option—Storage BuildingStorage YardRack StorageLiftIn Water Current Insurance Info: Current Insurance Company & Due Date List ALL Coverages (BI/PD | Comp Deductible | Med Pay | Collision Deductible | UM/UIM BI | UMPD | Other Coverages) Loss Settlement Type —Please choose an option—Total Loss ReplacementAgreed ValueACV If not insured, please list reason & date coverage went out of force Additional Info: Additional Drivers Additional Vehicles Additional Insured Do you own a home or rent? Boat Association Memberships If you have a copy of your current "Declaration Page", please forward that to us as proof of prior coverage and to use for comparison purposes. Submission of information for a quote in no way binds coverage. Personal information will be used solely for underwriting purposes. Submission of information gives the Gary J Bach Agency permission to run all reports necessary to quote accurate insurance premiums.
