Please fill out this form completely to receive your quote:
YOUR PERSONAL DATA
Name (required):
Street Address:
City
State:
Zip Code:
E-mail Address (required):
Phone Number:
Fax Number:
Multi-Ownership?Yes     NoProvide Details:
DRIVER INFORMATION 1
Name
GenderMale     Female
Marital Status
Years of Boating Experience
State of License
Date of Birth
Occupation
DRIVER INFORMATION 2
Name
GenderMale     Female
Marital Status
Years of Boating Experience
State of License
Date of Birth
Occupation
DRIVER INFORMATION 3
Name
GenderMale     Female
Marital Status
Years of Boating Experience
State of License
Date of Birth
Occupation
BOAT INFORMATION
Year
Make
Model
Serial Number
Cost New or Agreed Value
Boat Type
Hours Used Per Year
Length
Weight
Ownership
Lienholder
NAVIGATION & MOORING
Navigation Area (Include State)
InlandYes     No
CoastalYes     No
Summer Mooring
Winter Mooring
Lay-Up Dates From:
To:
TRAILER INFORMATION
Year
Make
Model
Serial Number
Cost New Value
Trailer Type
MOTOR INFORMATION
Year
Make
Model
Serial Number
Cost New Value
Motor Type
Engine Information:Total Horsepower:
Twin Engine?: Yes     No
VIOLATION INFORMATION
Driver 1 Driver 2 Driver 3
Minor violations - speeding, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless, hit and run, etc.
DEDUCTIBLE INFORMATION
Boat & Motor Trailer
Comp (theft)
Collison
COVERAGE INFORMATION
Bodily Injury Property Damage
Uninsured Motorist
Medical Payment -
Personal Liability
Fishing Equipment: -$
Personal Property:-$
MISCELLANEOUS INFORMATION
Any Youthful Operators? Yes  No Date of Birth:
Three years Boating Experience? Yes  No If No, how many?
Safety Course? Yes  No
Any Prior Boating Lessons? Yes  No Date and Amount:
Does the Boat have a Fire System? Yes      No
Any Commercial Usage? Yes      No
What is the Fuel Type? Gas      Diesel
List Electronic Aids in the Boat
Current Insurance Company
Expiration Date
Current Premium
Comments or Remarks:
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The Reinard Insurance Agency, Inc.
349 Bustleton Pike
Feasterville, PA 19053 (Directions)
Ph: 215-357-8600
Fx: 215-357-8061