BOAT INSURANCE

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

CUSTOMER INFORMATION

First Name:
Middle Initial:
Last Name:
Sex:	Male Female
Date of Birth:
Social Security Number :
Phone Number:
Marital Status:	Married Single Other
Home Address:
Email Address:
Driving Record (prior 35 months):
Number of/Nature of Tickets (all vehicles):
Number of/Nature of AF/NAF Auto and Boat/PWC Accidents
Automobile Driver License Status:
Primary Residence: (Discount for Home ownership; includes ownership of Mobile Home if less than 10 years old.)	Own Home/Condo Own Mobile Home less than 10 yrs old Rent Live with Parents Other

BOAT INFORMATION

Type (i.e. pleasure, fishing, sail, etc.):
Year:
Make:
Model:
Length:
Number of Engines:
Total Horsepower (excluding trolling and kicker motors):
Propulsion Type:	Inboard Outboard Inboard/Outboard Jet
Hull Material:
Enhanced Performance Modifications (i.e., blowers, superchargers, etc.):
Trailer Coverage:	Yes No
Rating Base* (include value of trailer and portable boating equipment if coverage desired): *Purchase price with taxes and title fees for TLR coverage or current market value for A/V, ACV coverage

UNDERWRITING INFORMATION

Dockage/Mooring/Storage Zip Code:
Watercraft Use (i.e., pleasure, business, etc.):	Pleasure Business Off-Road
Multi-Owner (more than one owner, not in the same household):	Yes No
Names of Regular Operators: Anyone with regular access to insured vehicle more than 12 times a year)
Names of Household Resident Operators:

COVERAGE INFORMATION

Hull Coverage:
Hull Deductible:
Liability Coverage Limits:
Uninsured/Underinsured Boater Coverage:
Medical Payments Coverage:
Primary Personal Effects Coverage:
Fishing Equipment Coverage (Primary):
Emergency Towing (on-water):
Coastal Navigation:

Note To Customer (in credit states only): To provide an accurate quote, we have asked you numerous questions about yourself and your motorcycle. As part of the quoting process, we will also be utilizing various consumer reports which may include reports regarding your credit history. All information we acquire may be provided to our insurance carriers.

Quotation Forms


Auto		Home		Boats		Motorcycles		Life		Business

321 S. Riverside Avenue - Box 190
Croton-on-Hudson, NY 10520-0190
(914) 271-5188
Fax (914) 271-9390

Hours: Monday - Friday 8:45- 4:45

E-mail: cathykaras@karasinsurance.com