Minnesota Jet Ski Insurance Rate Quote Request Page MN Personal Watercaft Liability Comprehensive Mini Boat

www.insuremn.com

Michael W. Smith Agency

Revised:

February 07, 2008

763-535-7293

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	Please tell me about any special concerns you have such as credit or claim problems.

This is a request for a Minnesota jet ski quote, not a policy application. Submitting this form does not obligate you to purchase any personal watercraft insurance products. Please complete this form as accurately as possible. Jet ski insurance rates are subject to change.

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General Information

Name
Street
City, State ZIP
E-mail
Phone
FAX

Residence Information

Primary Residence
Months at Address

Current Jet Ski Insurance Information

Current Insurance Co.	Expiration Date

Operator Information (please list all Operators)

Driver #1
Name	Birthdate	Sex	Marital Status	Years Experience

Social Security #		Drivers License #
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)

Driver #2
Name	Birthdate	Sex	Marital Status	Years Experience

Social Security #		Drivers License #
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)

Percentage of Use

	Driver 1.	Driver 2.
Watercraft 1.
Watercraft 2.

Jet Ski Information

Watercraft Unit 1.
Year	Make	Model	Number of CC's	Length

Horsepower	Maximum Speed	Storage	Years Owned	Value

Weight	Describe Any Accessories/Special Equipment Including Cost When New

Watercraft Unit 2.
Year	Make	Model	Number of CC's	Length

Horsepower	Maximum Speed	Storage	Years Owned	Value

Weight	Describe Any Accessories/Special Equipment Including Cost When New

Trailer Information

Year	Make	Model	Value

Coverage's

Liability Coverage. Pays for other people's injuries and damage to their property if you or someone else cause an accident while driving your watercraft. It protects your assets in the event you are held liable for damage to others.

Bodily Injury Liability Comment

Property Damage Liability

Medical Expense Coverage. If you and your passengers are injured in an watercraft accident, this coverage pays your medical expenses.

Medical Expense Comment

Uninsured and Underinsured Operators Coverage. Pays bodily injury claims if you or your passengers are injured by a negligent uninsured operator, hit-and-run operator or a negligent operator without adequate insurance.

Uninsured/Underinsured Comment

Comprehensive Coverage. Pays for damage to your watercraft caused by theft, fire, windstorm, vandalism and many other non-collision occurrences. Collision Coverage. If your watercraft collides with another watercraft or object, this coverage pays to repair your watercraft.
	Unit 1.	Unit 2.	Trailer
Comprehensive Deductible
Collision Deductible

Comments

Number of hits since August 15, 1998


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