Harris - Auto, Homeowners, Health, life, Motorcyle, Boat

Boat Quote (Florida Only)

You will be contacted within 1 business day by our agent

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION
Your Name:	First: Last:
E-Mail address:
Phone numbers:	Day Time:
	Evening:
	Fax:
How would you prefer to be contacted regarding your quote?	PhoneFaxEmail
If you would prefer to be contacted by phone, please let us know the best time to call.
Address:
City:
State:	(You must live in Florida)
Zip code:
Do you currently own your home, or rent?	RentOwn

PRIOR INSURANCE HISTORY
Currently insured with (company name not agency):		Num of Months Coverage:	Date Expires:

DRIVER HISTORY
Had a ticket in the last 3 years?	Had a license suspended or revoked in the last3 years?	Had a financial responsibility filing in the last 3 years?	Made any claims in the last 5 years?
Yes No	Yes No	Yes No	Yes No
If you answered yes to any of the above questions, please explain:

BOAT INFORMATION
Year:	Make:	Model:	Type:	Hull Material:

Length(feet):	Max Speed(mph):	Value:	Trailer Coverage	Trailer Value (if covered)
			YesNo

ENGINE INFORMATION
Make	Horsepower	Fuel Type	Propulsion
1.		GasDiesel
2.		GasDiesel

PERSONAL EFFECTS
Equipment	Value	Safety Equipment
Fishing equipment:		Auto Fire ExtinguisherYesNo
Electronic equipment:		Alarm System YesNo
Custom equipment:		Ligntning protection YesNo
Other (please specify):

COVERAGE OPTIONS>
Coverage Definitions Physical Damage:
Collision Deductible:
Comprehensive Deductible:
Bodily Injury Liability:
Property Damage:
Uninsured Boater:
Medical Payments:
Personal Effect: