First Driver/Operator Name:

Birth date:

M F

Marital Status

Married

Single

Drivers License Info

State

#

Street Address:

City and Zip

GA

E-Mail Address:

Phone Number:

Second Driver/Operator Name:

Birth date:

M F

Marital Status

Married

Single

Drivers License Info

State

#

Current Insurance:

Auto Only PWC

Current B/I or Liability Limits None 25/50 50/100 100/300 200/300 300/300 250/500 75 CSL 100 CSL 300 CSL 500 CSL 1,000 CSL

Years Experience

1 2 3 4 5 +

Any Accidents or Incidents

Vehicle 1– VIN #

Year and Make

Model and CCs

Added Accessory Coverage

Automatic Fire Extinguisher:

Yes  No

Original Cost  and Stated Value

PWC Length

Vehicle 2– VIN#

Year and Make

Model and CCs

Added Accessory Coverage

Automatic Fire Extinguisher:

Yes  No

Original Cost  and Stated Value

PWC Length

Liability Level Requested

$50,000 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000 $500,000

Example Liability Pricing:

$50,000= $60.00 or

$100,000= $76.00

$300,000= $112.00-suggested minimum

(for Illustration only purpose only)

Physical Damage Deductible:

Liability Only-No Physical Damage Coverage $100.00 $250.00 $500.00 $1,000.00 $2,500.00 $5,000.00  

Trailer Value

Comments:

As part of the application process, we may collect personal information from persons other than you or other individuals proposed for coverage, including credit reports and loss information reports.  This information, as well as other personal or privileged information subsequently collected by us, may in certain circumstances be disclosed to third parties without your authorization.  You have a right of access and correction with respect to all personal information we collect.  If you would like more detailed information in writing about our information collection practices, please let us know.

NOTE: In regard to the statement above, we are required to pos this as a process of obtaining Loss Information History and final quoting criteria.  Submitting this form approves the collection of data.  We have not asked for and do not require a social security number in this  process.

Your data will be held confidentially and will not be sold or distributed outside of our office.