In order to receive preliminary insurance and initial quote information please fill and send in the following form. Thank you!
NAME
MOORING ADDRESS
CITY STATE ZIP
YEAR / MANUFACTURER / MODEL / LENGTH (in feet) / / /
HULL TYPE
If other, please specify:
POWER
Jet
ENGINE & MOTORS
Total HP
NAVIGATIONAL WATERS (SF Bay, inland lakes, delta, etc.)
USAGE pleasure commercial racing other ------------- If other, please specify
ARE YOU CURRENTLY INSURED? Yes No
LOSS HISTORY (PAST THREE YEARS)
COVERAGE / LIMITS DESIRED Hull Value? Equipment / Personal Property Value? Bodily Injury / Property Damage Liability or Protection & Indemnity Limit of liability $300,000 $500,000 $1,000,000 Medical Payments Limit of liability $1,000 $5,000 $10,000
Uninsured Boatowners Limit of liability $300,000 $500,000 $1,000,000
Pollution
Trailer Value
General Comments / Additional Questions
How did you first discover or learn about us? WWW Magazine Newspaper Friend Other
Please contact me by:
Email
Phone If you'd like to be contacted by phone, please indicate the best time for us to call. BETWEEN Please select a time range 7AM - 12PM 12PM - 5PM 5PM - 8PM
Fax
Mail Address
Thank you for your time! - Plaza Insurance Sales, Inc.
