Patriot Agencies

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Watercraft Quote

PLEASE FILL OUT THE FORM BELOW AND SUBMIT FOR A FREE NO-OBLIGATION QUOTE FOR YOUR WATERCRAFT INSURANCE NEEDS:

NORTH CAROLINA RESIDENTS ONLY.

* = Mandatory

Name: *

Leave Blank:

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Organization:

Home Phone: *

Work Phone:

Fax:

Email: *

Driver 1

Name: *

License & State: *

Sex: *

Date of Birth: *

Tickets (Last 5 Years - Date, Violation): *

Accidents In The Last 5 Years AT FAULT (Date, $, Amount, Personal Injury): *

Accidents In The Last 5 Years NOT AT FAULT (Date): *

Number of Years Licensed: *

Marital Status: *

Good Credit History: Yes No

Number of Years Boating Experience: *

Driver 2

Name:

License & State:

Sex:

Date of Birth:

Tickets (Last 5 Years - Date, Violation):

Accidents In The Last 5 Years AT FAULT (Date, $, Amount, Personal Injury):

Accidents In The Last 5 Years NOT AT FAULT (Date):

Number of Years Licensed:

Marital Status:

Good Credit History: Yes No

Number of Years Boating Experience:

Driver 3

Name:

License & State:

Sex:

Date of Birth:

Tickets (Last 5 Years - Date, Violation):

Accidents In The Last 5 Years AT FAULT (Date, $, Amount, Personal Injury):

Accidents In The Last 5 Years NOT AT FAULT (Date):

Number of Years Licensed:

Marital Status:

Good Credit History: Yes No

Number of Years Boating Experience:

Driver 4

Name:

License & State:

Sex:

Date of Birth:

Tickets (Last 5 Years - Date, Violation):

Accidents In The Last 5 Years AT FAULT (Date, $, Amount, Personal Injury):

Accidents In The Last 5 Years NOT AT FAULT (Date):

Number of Years Licensed:

Marital Status:

Good Credit History: Yes No

Number of Years Boating Experience:

Watercraft Description

Length:

Weight:

Total HP:

Max Speed:

Fuel:

Engine Make:

Boat Year:

Boat Manufacturer:

Boat Purchase Date:

Boat Purchase Price:

Boat Current Price:

Engine 1 Year:

Engine 1 Manufacturer:

Engine 1 Purchase Date:

Engine 1 Purchase Price:

Engine 1 Current Price:

Engine 2 Year:

Engine 2 Manufacturer:

Engine 2 Purchase Date:

Engine 2 Purchase Price:

Engine 2 Current Price:

Trailer Year:

Trailer Manufacturer:

Trailer Purchase Date:

Trailer Purchase Price:

Trailer Current Price:

Equipment: Itemized equipment that is generally required to be onboard for the safe operation, navigation or maintenance of the watercraft. These items must be included in the total watercraft and equipment value or coverage will not be provided

List of Equipment (Item & value):

Coverage applies only to the territory defined - Check all that apply

V-Hull
Deep V
Bi-Hull

Has your coverage been cancelled or non-renewed: Yes
No

List all marine losses in the last 3 years:

Where is the boat stored in-season? Check appropriate box in each column

Open Parking Lot
Driveway/Yard
Locked/Fenced Area
Locked Building / Garage

Where is the boat stored in off-season? Check appropriate box in each column

Open Parking Lot
Driveway/Yard
Locked/Fenced Area
Locked Building / Garage

Additional Information: Please explain all "Yes" responses

Watercraft & Equipment Total Value: *

Personal Effects Total Value: *

Trailer Total Value: *

Liability 10/20/50
Limits: * 25/50/100
50/100/250
100/300/500
Other

Deductible: * $250
$500
$1000
$2500
$5000

Slipping And Yes
Mooring Liability: * No

Medical None
Payments: * $500
$1000
$2000

How would you like to receive your quote:

Watercraft Quote

Driver 1

Driver 2

Driver 3

Driver 4

Watercraft Description

Equipment: Itemized equipment that is generally required to be onboard for the safe operation, navigation or maintenance of the watercraft. These items must be included in the total watercraft and equipment value or coverage will not be provided

Boat Type

Hull Material

Hull Type

Coverage applies only to the territory defined - Check all that apply

Where is the boat stored in-season? Check appropriate box in each column

Where is the boat stored in off-season? Check appropriate box in each column

Additional Information: Please explain all "Yes" responses