Patrick Cooke Phone: 218-879-6500

612 1/2 Cloquet Ave
Insurance Agency Toll Free: 800-988-6550

Cloquet, MN 55720

Fax: 218-879-6907

pcooke@farmersagent.com

BOAT  QUOTE  REQUEST  FORM     

The following information is needed to quote a boat insurance policy. Print this page, fill out the information, and contact us via phone, fax, email, or stop by the office for a quote.

Last name of first named insured___________________ First name__________________ MI______
 
Date of birth of first named insured ______ / ______ / __________ Marital Status _______________
 
Years of boat ownership__________ Years of boating experience__________
 
State the vessel is registered in _______________ Primary state vessel is used in ________________
 
Zip code where the vessel is stored ____________________  Is the vessel homemade?  Y / N
 
 
Year of vessel______  Manufacturer____________  Model____________ Length_____ Top Speed_____
Value of hull, not including motors or trailer__________
 
Hull Material (Circle one)    Aluminum      Fiberglass      Fiberglass over wood      Wood      Steel      Composite
                                     Other (please specify) _________________________________________
 
Power type (Circle one)    Ouboard      Inboard     Inboard/Outdrive      Sailboat      Jet
 
# of main engines _____  Horsepower per main engine _____ Value of main engine(s) ___________
Trolling motor?  Y / N    Manufacturer_________    HP / Thrust______    Gas / Electric    Value______
 
Year of trailer_________  Manufacturer____________________  Trailer Value__________
 
 
Please answer the following questions for ALL operators:
 
Marine losses in last 5 years? Y / N   
 If yes, dates & details________________________________________________________________
 
Other losses in last 5 years, including motor vehicle, motorcycle, snowmobile, ATV, etc? Y / N
If yes, dates & details_________________________________________________________________
 
Violations / citations in last 5 years? Y / N
If yes, dates & details_________________________________________________________________
 
Any operators with a suspended license? Y / N
If yes, reason and date of suspension_____________________________________________________
Any unlicensed operators? Y / N
If yes, reason ________________________________________________________________________
 
Corporate ownership (for tax purposes only)? Y / N
Had watercraft insurance for past 12 months (with no lapse)? Y / N
 
Coverages Requested:
Boat and motor deductible (circle one)   $250    $500    $1000    $2500    $5000   Full Coverage Not Requested
 
Trailer deductible (circle one)    $250    $500   No Trailer Coverage Requested
 
Would you like personal property coverage? Y / N
If yes, amount requested (min $1000 to max $10,000)_________________
 
Towing and assistance coverage? Y / N
 
Liability limit (circle one)      $100,000      $300,000      $500,000
 
Would you like medical payments coverage? Y / N
If yes, amount requested (min $1000 to max $10,000)_________________
 
Would you like uninsured watercraft liability coverage? Y / N
If yes, amount requested (min $10,000 to max $500,000)_________________
 

In order to bind coverage, we may need more information. The quote is not guaranteed, and may change if information is different that disclosed on the quote request form.