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Michael W. Smith Agency

Revised:

May 06, 2015

Snowmobile

 763-535-7293

 

 

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

General Information

Name
Street
City, State ZIP   
E-mail
Phone
FAX

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Residence Information

Primary Residence
Months at Address

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Current Snowmobile 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.
Snowmobile 1.
Snowmobile 2.

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Snowmobile Information

Snowmobile Unit 1.
Year Make Model Number of CC's Years Owned
Garaged Value Describe Any Accessories/Special Equipment Including Cost When New
Yes
No

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Snowmobile Unit 2.
Year Make Model Number of CC's Years Owned
Garaged Value Describe Any Accessories/Special Equipment Including Cost When New
Yes
No

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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 Operators Comment

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Comprehensive Coverage. Pays for damage to your snowmobile caused by theft, fire, windstorm, vandalism and many other non-collision occurrences.

Collision Coverage. If your snowmobile collides with another vehicle or object, this coverage pays to repair your snowmobile.

Snowmobile 1. Snowmobile 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