Universal

Strickland Insurance Brokers
Monthly
Payment
Plan

Members of AICNC

Personal Watercraft Quote Form

Contact Information
Name (required)
Address
Address 2nd line
City
State
Zip
Contact me by Phone E-Mail Fax
EMail (req'd)
Work Phone Best Time
Home Phone Best Time
Fax
Current Insurance Information
Current Insurance Company (Not Agency)
Date Current Policy Expires mm/dd/yyyy
Your Personal Watercraft
  Unit 1 Unit 2
Year
Length (feet)
Manufacturer
Model
Engine size (cc)
Max Speed (mph)
Type of Craft
Purchase Price $ $
Date of Purchase mm/dd/yyyy mm/dd/yyyy
Storage Location
(if different from address given in Contact Information)
Used for Towing Sports
(skiing etc.)		 Yes No Yes No
Requested Coverage Limits
Insuring Amount

(Unit Only)
Trailer Value
Liability Limit (applies to all Units on the Policy)
Current Insurance
Current Insurer
Expiration Date of Current Policy mm/dd/yyyy
Requested Effective Date mm/dd/yyyy
Operators
Operator Operator Name Date of Birth
mm/dd/yyyy
1
2
3
4
Operator Driver License Number Years Licensed Years Boating Experience
1
2
3
4
Your Personal Watercraft
1
2
3
4
Driving Violations (not boating violations)
Incident Driver Involved Ticket / Violation
 Violation Date
mm/dd/yyyy
1
2
3
4
Questions, Comments or Concerns
This is a Request For Quotation Only.
No coverage is in effect until bound by an insurance carrier.

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