AJS Insurance - Watercraft Insurance On-Line Quote Form

Boat / Watercraft Insurance Quotation
-Boat -Personal Watercraft For the fastest and most accurate insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes only. *(Licensed in the states of AZ, NV and CA only)*

Personal Information

Name:

Social Sec #:

Address:

City: State: Zip:

Day Phone: Night Phone:

Best Time To Call: AM PM

Email Address:

Occupation:

Number of Years employed:

Type of Watercraft:

Please indicate the type of craft being quoted on this form:

Boat Waverunner Jet Ski Other

  Boat/Hull:       Built by:    Model:
                                         Year:    Length: ft.

  Motor:    Year:      Horsepower:
                      Top Speed:    Engine Size: (pers. Watercraft only) cc's

  Trailer:       Built by:    Year:

Coverages Desired

Boat/Watercraft: Limit Value: $

Motor: Limit Value: $

Trailer: Limit Value: $

Equipment & Accessories: Limit Value: $

Liability: Limit Value: $

Medical: Limit Value: $

Deductable: Limit Value: $

Driver Information

Name: Age:
Years Operating Experience: Gender:

#1 years Male
Female

#2 years Male
Female

#3 years Male
Female

#4 years Male
Female

Violations / Accidents

Please list any violations, accidents, or losses in the past 5 years

Driver Date Description Injuries At Fault

Yes Yes

Yes Yes

Yes Yes

Additional Comments/Questions

Please give any additional comments or questions you may have regarding this quotation.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

Website by Mohave Web

Personal Information
Name:
Social Sec #:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:
Occupation:
Number of Years employed:

Coverages Desired
Boat/Watercraft:	Limit Value: $
Motor:	Limit Value: $
Trailer:	Limit Value: $
Equipment & Accessories:	Limit Value: $
Liability:	Limit Value: $
Medical:	Limit Value: $
Deductable:	Limit Value: $

Driver Information
	Name:	Age:	Years Operating Experience:	Gender:
#1			years	Male Female
#2			years	Male Female
#3			years	Male Female
#4			years	Male Female

Violations / Accidents
Please list any violations, accidents, or losses in the past 5 years
Driver	Date	Description	Injuries	At Fault
			Yes	Yes
			Yes	Yes
			Yes	Yes