Woodbury Insurance Agency, Inc.

Boat/Watercraft Quote Request

Effective Date:

Your Name:

Your Mailing Address:

Street

City & State Zip

E-mail Address:

Daytime Phone #:

Choose One:

Please call me with quote premium.
Please send quote via e-mail.

Description of Property:

Motor type:
Number of Engines:
Boat Type:
Other Boat Type

Fuel:
Maximum Speed:
Hull Material:
Other Hull Material:

Insured Watercraft:

Boat:
Year        Manufacturer                              Model

Serial Number                                                     Length           TotalHP

Outboard Motor:
Year        Manufacturer                              Model

Serial Number                                                     TotalHP

Trailer:
Year        Manufacturer                              Serial Number

Coverages: Limits:

Boat (Including Auxiliary Equipment, please break down o/b information)

Outboard Motor 1.
(ACV Coverage)

Outboard Motor 2.
(ACV Coverage)

Boat Trailer

Personal Property
($500 Automatic)

Commercial Towing
($400 Automatic)

Boat Liability
(ACV Coverage)

Medical Payments
($1000 Automatic with Liability)

Uninsured Boater

Optional Coverages
Agreed Value Endorsement
Actual Cash Value
Fishing Equipment - Limit:

Safety Equipment:
Check all that apply:

GPS
Automatic CO2 (Halon)
Ship to Shore Radio (VHF)
Depth Sounder
Electronic Burglar Alarm Radar
Plotter
EPIRB
Vapor Detector Alarm

Operator Information:

Date of Birth:
Years of Boating Experience:

Waters to be Navigated:

Inland waters of the following states:
Coastal waters of the following states:

Is the boat chartered or used for other than private pleasure purposes? Yes No

Previous Loss Information
Please describe any losses or claims filed on your Boat Insurance in the last 3 years:

Date of loss: Type of loss: Amount of claim:

Additional Comments
Please use the box below to enter any additional information you wish to include:

We cannot bind coverage from an email or voicemail request. Coverage is bound after you receive a written email or telephone confirmation from an agency staff member.

If you have not received a response from us within one business day, please contact us again.

Thank you.

We cannot bind coverage from an email or voicemail request. Coverage is bound after you receive a written email or telephone confirmation from an agency staff member. If you have not received a response from us within one business day, please contact us again. Thank you.

We cannot bind coverage from an email or voicemail request. Coverage is bound after you receive a written email or telephone confirmation from an agency staff member.

If you have not received a response from us within one business day, please contact us again.

Thank you.