Insurance Massachusetts — Insurance For You

Small enough to know you... Big enough to serve you

280 Worcester Rd.
Framingham, MA 01702
Tel:	(508) 620-9060
	(617) 285-3367
Fax:	(508) 620-9059

Click a photo below for the corresponding insurance application

For a confidential Marine Insurance quote, please fill out the following form.

Your Personal Information

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Phone Number:

E-Mail Address:

Date of Birth:

Number of Years of Boating Experience:

Boating Courses/Licenses:

Claims in the last 5 Years:

Please tell us about your craft
Personal Watercraft (PWC) Information

Make:

Model:

Year of Make:

Speed:

Year Purchased:

Is This Craft Financed?

Yes

Trailer Coverage

Prior Boats Owned

1. Type:

Size:

Years Owned:

2. Type:

Size:

Years Owned:

3. Type:

Size:

Years Owned:

Vessel Use

Navigated Year Round?

Yes

if No... Laid Up On Land:

From to

Navigation Area:

Fresh Water

Salt Water

Overnight Storage (Summer):

Other Operator Information*

			MVR info for last 4 Yrs		# DUI
Name	Age	Occupation	# Tickets	# Accidents	last 6 Yrs

*No claim is covered while craft is operated by someone without a valid driver's license unless prior written approval is obtained.

Coverage Requested

Deductible:

$500

$1,000

P & I Liability Limit:

Present Insurer (or Previous Insurer if you have none):

Expiration Date:

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