Kasmer Insurance Agency, L.L.C.: Boat Quote

Effective Date:
Your Name:
Current Address:	Street	Prior Address: (If less than 2yrs at current address)	Street
	City, State & Zip		City, State & Zip
Phone:		Please call me with quote premium. Please send quote via e-mail.
Email:

Description of Property:
Motor type:	Number of Engines:	Boat Type:	Other Boat Type
Fuel:	Maximum Speed:	Hull Material:	Other Hull Material:

Insured Watercraft:
Boat:	Year	Manufacturer	Model	Serial Number	TotalHP	Length

O/B Motor:	Year	Manufacturer	Model	Serial Number	TotalHP

Trailer:	Year	Manufacturer		Serial Number

Is the boat chartered or used for other than private pleasure purposes? Yes No

Coverage:	Limits:	Optional Coverages:
Boat	(incl. aux equip)	Agreed Value Endorsement Actual Cash Value Fishing Equipment Limit:
O/B Motor 1.	(ACV Coverage)
O/B Motor 2.	(ACV Coverage)
Boat Trailer
Pers. Property	($500 Automatic)
Towing	($400 Automatic)
Boat Liability
Medical Payments	($1000 Automatic)
Uninsured Boater

Safety Equipment:
GPS Automatic CO2 (Halon) Ship to Shore Radio (VHF)	Depth Sounder Electronic Burglar Alarm Radar	Plotter EPIRB Vapor Detector Alarm

Operator Information:
DOB:
Years of experience:

Waters to be Navigated:
Inland waters of the following states:
Coastal waters of the following states:

Previous Loss Information
Please describe any losses or claims filed on your Boat
Insurance in the last 3 years.Include the date and type of the loss, as well
as the amount of the claim

Additional Comments
Please use the box below to enter any additional information
you wish to include:

Agreement & Disclaimer

Thank you for requesting a quote from our agency. We are pleased to provide you with multiple ways to communicate your insurance needs to us, however please note:
Coverage via this online request is NOT bound until you have received a written acknowledgement from our office.
*Protecting your privacy and identity is very important to us. Your Social Security number is required to complete a quote. You can send it to us securely by entering it on this form, however we will contact you personally if you prefer to omit this information online.
- Please be aware that we may use your social security number to run a credit check. We may also run an MVR (motor vehicle report) and a CLUE report of loss information. These reports are necessary for any and all insurance quotes we provide either online or in person.
By clicking "Submit" you acknowledge that you understand and agree to this information.

Boat & Watercraft Insurance Quote Request

Agreement & Disclaimer