Le Claire Insurance

J L Le Claire & Sons Insurance Agency

The Protection and Security you would expect from Family

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Boat Quote

Boat Insurance Quote Request Complete the following information if you would like to obtain a quote. Please understand this is not an application. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Mooring Storage Location
Registration State
Marina/Location Name
Street Address
City
State
Zip Code
Type of Location
Type of security
Named Insured
Last Name
First Name
Street Address
City
State
Zip Code
Telephone
Email
Social Security Number
Date of Birth
Driver 1 Information
First Name
Last Name
Gender	Male Female
Birth Date
Marital Status
Years boating experience
State Licensed
Relationship to Named Insured
Driver 2 Information
First Name
Last Name
Gender	Male Female
Birth Date
Marital Status
Years boating experience
State Licensed
Relationship to Named Insured
Driver 3 Information
First Name
Last Name
Gender	Male Female
Birth Date
Marital Status
Years boating experience
State Licensed
Relationship to Named Insured
Driver 4 Information
First Name
Last Name
Gender	Male Female
Birth Date
Marital Status
Years boating experience
State Licensed
Relationship to Named Insured
Boat Information
Primary Waters Navigated
State
Inland or Coastal	Inland Coastal
Year
Make
Model
Type
Identification Serial Number
Cost New Value
Hours Used Each Year
Boat Length
Watercraft Weight
Ownership
Hull Material
Fuel Type
# of Engines
Maximum Speed (MPH)
Horsepower of each Engine
Trailer Information
Year
Make
Model
Type
Identification Serial Number
Cost New Value
Motor Information
Year
Make
Model
Type
Identification Serial Number
Cost New Value
Horsepower or Motor Size
Ownership
Deductible Information - Boat & Motor
Deductible
Deductible Information - Trailer
Deductible
Violation Information - Last 3 years (minor violations) / Last 5 years (major violations)
Driver 1
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 2
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 3
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 4
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Coverage Information
Personal Liability
Medical Payments
Uninsured Watercraft Coverage
Personal Property Coverage (Amount)
Personal Property Replacement Cost Coverage	Yes No
Towing and Assistance
Miscellaneous Information
Does the Boat have a Fire System?	Yes No
Any Commercial Usage?	Yes No
List Electronic Aids in the boat
Current Insurance Company
Expiration Date
Current Premium
Questions or Comments

Boat Insurance Quote Request

Mooring Storage Location

Named Insured

Driver 1 Information

Driver 2 Information

Driver 3 Information

Driver 4 Information

Trailer Information

Motor Information

Deductible Information - Boat & Motor

Deductible Information - Trailer

Violation Information - Last 3 years (minor violations) / Last 5 years (major violations)

Driver 1

Driver 2

Driver 3

Driver 4

Coverage Information

Miscellaneous Information