Jersey Marine

Insurance Quote Form

Personal Information

1. Name(required)
2. Email(valid email required)
3. Date of Birth(required)
4. Drivers License Number(required)
5. Driving Violations
6. Address(required)
7. City(required)
8. State(required)
9. Zip(required)
10. Home Phone(required)
11. Cell Phone(required)
12. Work Phone(required)
13. Current Insurance Company
14. Expiration Date
15. How Many Years Boating
16. Boating Courses or Capt. License
17. List Prior Boats Owned & How Many Years
18. Prior Boat Losses

Boat Information

1. Hull Value or Purchase Price
2. Year
3. Make
4. Length
5. Model
6. Engine Manufacturer
7. Engine Hours
8. Motor Choose One I/O OB IB
9. Power Choose One Gas Diesel
10. HP & Model
11. Number of Engines
12. Navigation Area
13. Summer Location & Zip Code
14. Winter Location & Zip Code
15. Primary Use Choose One Employed Crew Private Pleasure Use Charter/Occupational Charter

Equipment

1. Please check all that apply
2. Generator Loran Halon (co2) VHF Radar Anti-Theft
   GPS Cameras Life Raft Eperb

Trailer

1. Manufacture
2. Model/Size
3. Year
4. Value

Navigational Limits

1. Navigational Limits
2. New York, New Jersey, Deleware, Maryland Area
   Eastport, ME to Cape Ann, ME
   Eastport, ME to Atlantic Highlands, NJ
   Inland
   Eastport, ME to Savannah, GA
   Chesapeake

Additional Information

1. Hull Equipment Value
2. Fishing Equipment
3. Personal Effects
4. Tender $
5. Deductible Choose One 1/2% 1% 2% 3%

 

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