Fred Simmons Insurance


BOAT INSURANCE QUOTE FORM

First Name MI Last Name

Physical Address
City State
Mailing Address
City State
Home Phone
Work Phone
Email (required)
How did you hear about Fred Simmons Marketing Insurance, Inc?
What carrier are you currently with?
What is important to you when buying insurance? (5 being highest importance)
Coverage :
1 2 3 4 5
Price :
1 2 3 4 5
Reputation :
1 2 3 4 5
Value :
1 2 3 4 5
Agent :
1 2 3 4 5
Carriers name :
1 2 3 4 5

What is it that you like or dislike about your current insurance carrier?

Present Auto Insurance Carrier (enter 'none' if no present carrier)
Renewal Date
Do you own your own home? yes      no

Watercraft Information
Year Make Model
Hull Length        Total Horsepower       # of Motors  
Propulsion Type       Hull Material
Is boat modified for engine performance? yes      no
Current Market Value of Watercraft
Storage/Mooring Zip Code
Registration (CF number)
Hull ID

Trailer Information
Year Make Model
Registration #

DRIVER INFO:

Driver #1
First Name Last Name
Occupation Business
Drivers License Number
Date of Birth
Gender male       female
Marital Status
Moving Violations in last 3 years: 0    1    2   3
Briefly describe all violations (include dates):
Accidents in last 3 years: 0    1    2   3
Briefly describe all accidents, include date and whether at fault or not at fault:

Driver#2
First Name Last Name
Occupation Business
Drivers License Number
Date of Birth
Gender male       female
Marital Status
Moving Violations in last 3 years: 0    1    2   3
Briefly describe all violations (include dates):
Accidents in last 3 years: 0    1    2   3
Briefly describe all accidents, include date and whether at fault or not at fault:

Driver#3
First Name Last Name
Occupation Business
Drivers License Number
Date of Birth
Gender male       female
Marital Status
Moving Violations in last 3 years: 0    1    2   3
Briefly describe all violations (include dates):
Accidents in last 3 years: 0    1    2   3
Briefly describe all accidents, include date and whether at fault or not at fault:

Comments:

CA License #OC17932

Privacy notice:
Fred Simmons Insurance Marketing, Inc. insures your privacy. We will include a copy of our Privacy Statement upon request.

This conditional quote is based on the the information you provide(d), and is subject to final approval by the carriers' underwriters.


Fred Simmons Insurance, Inc.
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