Blake, Hall & Allen Insurance
Watercraft Quote Request Form

Please provide the information below to receive a
Watercraft Insurance quotation for the
State of Maine.

We will email your quote, usually within one business day.
Submit as many optional quote requests as you would like.

To ensure accuracy, and to reduce your entry time,
you might want to have your current policy in front of you.

Name:                     

Address:                 

City:                         , MAINE     Zip:

Phone #:                 

Email Address:     

Current Coverage Information

Have you had continuous Watercraft Insurance for the past year? Yes No:

Watercraft Operators In The Household

                             Gender &         Driving
  Driver Name       DOB    Marital Status    Experience    Occupation

1:       

2:       

3:       

4:       

Have any operators completed a Certified Boating Safety Course?
    Operator 1       Operator 2      Operator 3      Operator 4

Accidents and Violations

Please indicate if any operators in the household have had accidents or violations in the last THREE years. Provide details of each accident or violation in the space provided below, including: what type;how many; when; where; how much was paid for the accident; and circumstances.

Does Operator # 1 Have any of the following?
Moving Violations Not at Fault Accidents At Fault Accidents

Does Operator # 2 Have any of the following?
Moving Violations Not at Fault Accidents At Fault Accidents

Does Operator # 3 Have any of the following?
Moving Violations Not at Fault Accidents At Fault Accidents

Does Operator # 4 Have any of the following?
Moving Violations Not at Fault Accidents At Fault Accidents


Accident/Violation Details



Watercraft Description

Type of Watercraft: 
Modified For Performance? 
Year        Mfr. & Model Name        Model Number     Length
    

  Purchase Date    Purchase Price 
   


   Docking Location       Winter Lay-up Location  Waters Navigated
   


Total Value Of Unattached Watercraft Accessories: $

Motor Description

Type of Motor:

Number of Motors:     hp Each:      Max M.P.H.:

Purchase Date:            Purchase Price: $

Trailer Description

Year:     Manufacturer:     Model:

Purchase Date:      Purchase Price:

Watercraft Liability Coverage Information

Bodily Injury and Property Damage limits of liability:

Medical Payments Coverage
Uninsured Boaters Coverage Limits (optional):

Physical Damage Coverage

Physical Damage Deductible:

Remarks

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