This form is used for RV, Boat, Cycle, Snowmobile, ATV, Scooter, Segway and Golf Carts. Kindly complete this form and submit so we can prepare your insurance quote.

General Information

Name: *

Address:

City: State: Zip:

Day Phone:

Evening Phone:

Best time to contact: AMPM

E-mail address: *

Occupation:

Current Insurance Section

Company: (Not Agency, If no current insurance mark "none")

Policy Expiration Date: (xx/xx/xxxx)

Annual Premium:

Term:
6 months1 year

Driver Section

Driver 1

Driver's Name:

Date of Birth:

License Number:

State: Years Licensed:

Relation:

Gender: MaleFemale

Marital Status: SingleMarried

Driver 2

Driver's Name:

Date of Birth:

License Number:

State: Years Licensed:

Relation:

Gender: MaleFemale

Marital Status: SingleMarried

Driver 3

Driver's Name:

Date of Birth:

License Number:

State: Years Licensed:

Relation:

Gender: MaleFemale

Marital Status: SingleMarried

Driver 4

Driver's Name:

Date of Birth:

License Number:

State: Years Licensed:

Relation:

Gender: MaleFemale

Marital Status: SingleMarried

Vehicle Section

Unit 1 (boat, cycle, rv, atv, snowmobile, golf cart, segway)

Make:

Model: Year:

Horsepower, CC:

Hull Construction:

Inboard /Outboard/ Inboard Outdrive:

Unit / Vehicle Value (stock / factory):

Value of non factory Installed accessories:

Safety Features:

VIN / Serial Number:

Primary Driver:

Maximum Speed:

Annual Miles:

Waters Navigated:

Garaging Zip Code:

Is this unit used off road only?
YesNo

Is this unit / vehicle stored in a garage of secured building?
YesNo

Unit 2 (boat, cycle, rv, atv, snowmobile, golf cart, segway)

Make:

Model: Year:

Horsepower, CC:

Hull Construction:

Inboard /Outboard/ Inboard Outdrive:

Unit / Vehicle Value (stock / factory):

Value of non factory Installed accessories:

Safety Features:

VIN / Serial Number:

Primary Driver:

Maximum Speed:

Annual Miles:

Waters Navigated:

Garaging Zip Code:

Is this unit used off road only?
YesNo

Is this unit / vehicle stored in a garage of secured building?
YesNo

Unit 3 (boat, cycle, rv, atv, snowmobile, golf cart, segway)

Make:

Model: Year:

Horsepower, CC:

Hull Construction:

Inboard /Outboard/ Inboard Outdrive:

Unit / Vehicle Value (stock / factory):

Value of non factory Installed accessories:

Safety Features:

VIN / Serial Number:

Primary Driver:

Maximum Speed:

Annual Miles:

Waters Navigated:

Garaging Zip Code:

Is this unit used off road only?
YesNo

Is this unit / vehicle stored in a garage of secured building?
YesNo

Unit 4 (boat, cycle, rv, atv, snowmobile, golf cart, segway)

Make:

Model: Year:

Horsepower, CC:

Hull Construction:

Inboard /Outboard/ Inboard Outdrive:

Unit / Vehicle Value (stock / factory):

Value of non factory Installed accessories:

Safety Features:

VIN / Serial Number:

Primary Driver:

Maximum Speed:

Annual Miles:

Waters Navigated:

Garaging Zip Code:

Is this unit used off road only?
YesNo

Is this unit / vehicle stored in a garage of secured building?
YesNo

Coverage Section

Liability and First Party Benefits

Bodily Injury:

Single Limit:

Uninsured & Underinsured Motorist Split Limits Coverage:

Uninsured & Underinsured Motorist Single Limit Coverage:

Uninsured & Underinsured Motorist: StackedUnstacked

Extraordinary Medical Benefits:

First Party Medical Benefits:

Accidental Death Benefits:

Income loss:

Funeral Benefits:

Towing Coverage:

Rental Reimbursement / Loss of Use:

Tort Option:

Deductibles and Miscellaneous

Unit 1

Deductibles

Comprehensive:

Collision:

TowingRental Reimbursement / Loss of Use

Unit 2

Deductibles

Comprehensive:

Collision:

TowingRental Reimbursement / Loss of Use

Unit 3

Deductibles

Comprehensive:

Collision:

TowingRental Reimbursement / Loss of Use

Unit 4

Deductibles

Comprehensive:

Collision:

TowingRental Reimbursement / Loss of Use

Additional Questions and Comments

In order to provide you with an accurate quote the company will obtain your credit insurance score and additional reports to verify the driving records and claims history for the person / persons applying for the insurance. This will not have an effect on your credit history.

* I have read the Information Disclosure and accept the above terms and conditions

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General Information

Current Insurance Section

Driver Section

Vehicle Section

Coverage Section

Additional Questions and Comments

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