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Michael W. Smith Agency

Revised:

May 06, 2015

Jet Ski / PWC

 763-535-7293

 

 

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Information

 

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

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Current Jet Ski Insurance Information

Current Insurance Co.

Expiration Date

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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)

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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)

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Percentage of Use

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

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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

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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

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Trailer Information

Year Make Model Value

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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

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

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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

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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

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Comments

 

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Number of hits since August 15, 1998

 

 

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Copyright 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009 Michael W. Smith Agency