Watercraft Questionnaire

This field is for validation purposes and should be left unchanged.

Full Name(Required)

Phone Number

Email Address(Required)

Home Address (Also Prior if < 60 days)

Please provide the following information for EACH DRIVER of the watercraft

Full 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

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?

Where is the boat stored during the off season?

Current Insurance Information

Current Insurance Company & Due Date

Loss Settlement Type

If not insured, please list reason & date coverage went out of force

Additional Information

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.