Boat, Yacht & Jet Ski
Insurance Request Form

To receive a quote, please fill out the form below.....
Name:
Address:
City, St., Zip:
Phone Number:
E-Mail Address:

Current Carrier Information and Expiration date of policy?
Company Name: Expiration date:

Liability Limits.....
Bodily Injury per Person / Bodily Injury per Accident / Property Damage per Accident

Property Coverages Information...
Deductible Boat Length Type Weight of Boat Speed
feet   lbs Max. Speed:

YEAR MAKE/MODEL HULL WHERE USED INSURED
VALUE
Boat
$
Motor
Horse Power: 
$ 
Trailer: $ Accessories...:$

Driver Information...

Driver Name BirthDate Sex Marital Status Yrs  Licensed Boating Experience
1 
Safety Courses:  Yes  / No Date of Course: 
Driver Name
BirthDate
 Sex Marital Status Yrs Licensed Boating Experience
2 
Safety Courses:  Yes  /No Date of Course: 
Driver Name BirthDate Sex Marital Status Yrs Licensed Boating Experience
3 
Safety Courses:  Yes  / No Date of Course: 
Driver Name BirthDate Sex Marital Status Yrs Licensed Boating Experience
4 
Safety Courses:  Yes  / No Date of Course: 

Accidents and Violations....
Does any driver have any accidents or violations in the last 3 years?   Yes     No

If YES, Please list ANY violations or accidents within last 3 years.......
DATE DRIVER NAME TYPE OF OCCURRENCE
1 
2 
3 
4 

Which association do you belong? 
 
 

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474           (fax) 327-7911
Toll Free: 1-800-977-2999      Fax: 1-888-800-0034