Named Insured
Name:
Address:
City/State/Zip:				/ /
Phone:
Fax:
Email:
Preferred Response Method:				Email Fax Phone
Watercraft Type
This quote request is for a:				BOAT JETSKI
Operator Information
Name:		User 1
		User 2
		User 3
		User 4
Date of Birth:		User 1
		User 2
		User 3
		User 4
Drivers License #:		User 1
		User 2
		User 3
		User 4
License State of Issue:		User 1		Select State Massachusetts Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Michigan Minnesota Misissippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington Washington D.C.
		User 2		Select State Massachusetts Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Michigan Minnesota Misissippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington Washington D.C.
		User 3		Select State Massachusetts Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Michigan Minnesota Misissippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington Washington D.C.
		User 4		Select State Massachusetts Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Michigan Minnesota Misissippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington Washington D.C.
Years Watercraft Experience:		User 1
		User 2
		User 3
		User 4
Minor Violations Last 3 Years: (List Month/Year for each incident.)    "mm/yyyy, mm/yyyy,.."		User 1
		User 2
		User 3
		User 4
Major Violations Last 3 Years: (List Month/Year for each incident.)    "mm/yyyy, mm/yyyy,.."		User 1
		User 2
		User 3
		User 4
At-Fault Accidents Last 3 Years: (List Month/Year for each incident.)    "mm/yyyy, mm/yyyy,.."		User 1
		User 2
		User 3
		User 4
Description of Watercraft
Year:
Make:
Model:
Serial #:
Max HP (Boats) or CC (JetSkis)				"## HP" or "## CC"
Length:				feet
Max Speed:				mph
New/Used				New Used
Registration #: (Boats)
1,2 or 3 Passenger: (JetSkis)				1 Passenger 2 Passenger 3 Passenger
State of Navigation:				Select State Massachusetts Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Michigan Minnesota Misissippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington Washington D.C.
Purchase Date:				"mm/dd/yyyy"
Purchase Price:				$
Describe any permanently installed or custom equipment:
Description of Motors (Boats)
Year:		Motor #1
		Motor #2
Make:		Motor #1
		Motor #2
Serial #:		Motor #1
		Motor #2
HP:		Motor #1
		Motor #2
Year Rebuilt: (if applicable)		Motor #1
		Motor #2
Description of Trailer(s)
Year:      "yyyy, yyyy, ..."
Make:     "make, make, ..."
Serial #:   "##, ## ..."
Additional Items On Board Boat
Miscellaneous Equipment: "Item Description, $ Value, Item Description, $ Value, ..."
Personal Effects: "Item Description, $ Value, Item Description, $ Value, ..."
Detailed Boat Information
Boat Type:				Outboard Inboard Inboard/Outboard Jet Powered Sailboat Houseboat Pontoon
				Other
Boat Construction:				Fiberglass Wood Metal Aluminum Steel
				Other
Area of Navigation:				Inland Waters Great Lakes Gulf Coastal < 3 Miles Gulf Coastal 3-25 Miles Atlantic Coastal < 3 Miles  Atlantic Coastal 3-25 Miles Pacific Coastal < 3 Miles Pacific Coastal 3-25 Miles SanFancisco Bay (not west of                                              Golden Gate) Lake Powell/Mead Yes No Is extended coastal navigation desired?
Garaging/Mooring During Period of Use:				Driveway/Yard/Garage Private Storage Apt/Townhouse Lot Mobile Home Park Marina Slip
				Other
Garaging/Mooring During Lay Up:				Driveway/Yard/Garage Private Storage Apt/Townhouse Lot Mobile Home Park Marina Slip
				Other
Watercraft Losses in Last 3 Years
Date of Loss:		Loss 1		"mm/dd/yyyy"
		Loss 2		"mm/dd/yyyy"
		Loss 3		"mm/dd/yyyy"
Cause of Loss:		Loss 1
		Loss 2
		Loss 3
Describe damage to watercraft and equipment:		Loss 1
		Loss 2
		Loss 3
Was anyone injured? Please explain:		Loss 1
		Loss 2
		Loss 3
$ Amount of Damage:		Loss 1		$
		Loss 2		$
		Loss 3		$
General Boat Information
In what state is the boat primarily navigated?				Select State Massachusetts Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Michigan Minnesota Misissippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington Washington D.C.
How many years has the principal operator maintained and operated a watercraft?
Has engine been turbocharged, supercharged, altered or modified in any way for the purpose of enhancing speed or performance?
Is this boat the primary residence of the insured?				Yes No
Is this boat titled in the name of or used in the course of the insured's business? Note: Coverage is limited to private pleasure use of owner.
Is this boat owned by others in addition to the named insured? Note: Maximum of three owners for coverage eligibility.
Is craft permanently moored? If yes, Where (Including Zip Code)
Is this boat currently for sale by the insured?				Yes No
Is the insured boat used for water-skiing? (power boats only) If yes, is water-skiing liability coverage desired?
Has the principal operator of the boat completed either the US Coast Guard Auxiliary or US Power Squadron introductory courses? (Completion Certificate will be required)
Is your motor's propeller construction other than stainless steel?
General JetSki Information
Is personal watercraft modified in any way to enhance speed or performance? If yes, please explain.
Is personal watercraft used in any race or exhibition? Please Note - No coverage for race or exhibition.
Is personal watercraft titled in the name of or used in the course of the insured's business? Note: Coverage is limited to private pleasure use of owner.
Is personal watercraft currently held for sale and if so, how long has it been for sale?
Where will personal watercraft be stored when not in use? (Including Zip Code)
Thank You. You have completed the form. Add any general comments in the box below, then click the "Submit" button. We will respond to you promptly. Thank you for considering Pacheco Insurance for your insurance needs.
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