Insurance Products

Boat Insurance Quote

Enter and submit the information below and a U.S. Insurance Services representative will contact you promptly with a quote for your requested coverage.

Personal Info

First Name*	MI	Last Name*
Address*		Home Phone*
		Work Phone
City, State, Zip*		Email*
How would you like us to contact you? Email: Phone:

Prior Policy

Have you had coverage during the past 12 months? Yes No
Policy Number		Policy Expiration Date
Company		Agency

Operator Info

First Name*	MI	Last Name*
Date of Birth*		Gender*	Male Female
Driver's License Number		State*
Relation*		Marital Status*

Tickets, Claims, Accidents, or Violations in the past three years:
Date	Description

Primary Residence:*
Highest level of Education:*
Occupation:*
Years of Boat Ownership:

Operator #2 Info
First Name MI Last Name
Date of Birth		Gender	Male Female
Driver's License Number		State
Relation		Marital Status
Tickets, Claims, Accidents, or Violations in the past three years:
Date	Description

Operator #3 Info
First Name MI Last Name
Date of Birth		Gender	Male Female
Driver's License Number		State
Relation		Marital Status
Tickets, Claims, Accidents, or Violations in the past three years:
Date	Description

Operator #4 Info
First Name MI Last Name
Date of Birth		Gender	Male Female
Driver's License Number		State
Relation		Marital Status
Tickets, Claims, Accidents, or Violations in the past three years:
Date	Description

Operator #5 Info
First Name MI Last Name
Date of Birth		Gender	Male Female
Driver's License Number		State
Relation		Marital Status
Tickets, Claims, Accidents, or Violations in the past three years:
Date	Description

Operator #6 Info
First Name MI Last Name
Date of Birth		Gender	Male Female
Driver's License Number		State
Relation		Marital Status
Tickets, Claims, Accidents, or Violations in the past three years:
Date	Description

Operator #7 Info
First Name MI Last Name
Date of Birth		Gender	Male Female
Driver's License Number		State
Relation		Marital Status
Tickets, Claims, Accidents, or Violations in the past three years:
Date	Description

Operator #8 Info
First Name MI Last Name
Date of Birth		Gender	Male Female
Driver's License Number		State
Relation		Marital Status
Tickets, Claims, Accidents, or Violations in the past three years:
Date	Description

Add another operator

Unit info

What county is the craft moored in?*
Year:*		Make*
Model:*		VIN Number*
Ownership*
Mooring Type:*		Waters Navigated:*
Length (in feet):*		*Purchase Price:Including Motor(s)**
Boat Type:*		Corporate Owned: * Yes No

Protection Devices:*

None

Automatic Fire Extinguishers

Central Station Monitoring System

Alarm System (High Water/Fire/Theft)

No Strike Lightning System

Number of Additional Owners:* (Excluding resident relatives of the first name insured)

List Any Additional Owners:*

Motor info

Year:*		Make:
Model:		VIN Number
HP:*
Motor Type:*		Fuel Type:*

Add another motor

Coverages

Include Medical Payments Coverage:	Yes No
*Liability (CSL):Requires a copy of your umbrella policy**
Personal Property: Enter an amount rounded to the nearest $100
Personal Property Replacement cost: Yes No	Include Uninsured Boaterist Coverage:*
Trailer Coverage:*	Hull deductible*
Hull Physical Damage Deductible %: *Note: minimum deductibles apply	Hull Physical Damage Type: *Note: Unit age restrictions apply
Include Towing Coverage:	Yes No
Personal Effects Coverage:

How did you hear about us:

If you received a card from a dealer that has an RBB number on it, enter it here. Or, if you cannot locate the RBB number, type the Dealership's name here:

or call 866-372-9693

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