Watercraft Insurance Survey

Contact Information
Client Name
Contact Name
First Last
Phone Number
Email Address
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
How did you find out about IRMS?
Other
Driver Information
Current Carrier/Prior Insurance
When do you want your policy to be effective?
MM slash DD slash YYYY
Driver #1 Information
Name
First Last
Gender
Marital Status
Date of Birth
MM slash DD slash YYYY
Drivers License #
How many years of experience do you have in boating?
Any Violations/Accidents? (Last 3 Years)
Add a second driver?
- Yes
Driver #2 Information
Name
First Last
Gender
Marital Status
Date of Birth
MM slash DD slash YYYY
Drivers License #
Any Violations/Accidents? (Last 3 Years)
Add a third driver?
- Yes
Driver #3 Information
Name
First Last
Gender
Marital Status
Date of Birth
MM slash DD slash YYYY
Drivers License #
Any Violations/Accidents? (Last 3 Years)
Add a forth driver?
- Yes
Driver #4 Information
Name
First Last
Gender
Marital Status
Date of Birth
MM slash DD slash YYYY
Drivers License #
Any Violations/Accidents? (Last 3 Years)
Watercraft #1 Information
Watercraft Information
Watercraft Year Watercraft Make Watercraft Model Watercraft Length
Watercraft Value
Hull ID Number
Motor Year
Motor Make
How many motors?
Motor Horsepower
Motor Propulsion
Motor Value
Motor Serial Number
Trailer Information
Trailer Year Trailer Make Trailer Model Trailer Value
Trailer Serial Number
Other Equipment Description/Value
Mooring or Storage Location
Watercraft Maximum Speed
Current Insurance Carrier
Current Limits of Liability
Add second watercraft?
- Yes
Watercraft #2 Information
Watercraft Information
Watercraft Year Watercraft Make Watercraft Model Watercraft Length
Watercraft Value
Serial Number
Motor Year
Motor Make
How many motors?
Motor Horsepower
Motor Propulsion
Motor Value
Motor Serial Number
Trailer Information
Trailer Year Trailer Make Trailer Model Trailer Value
Trailer Serial Number
Other Equipment Description/Value
Mooring or Storage Location
Watercraft Maximum Speed
Current Insurance Carrier
Current Limits of Liability
Coverage Information
Bodily Injury Liability
Property Damage Liability
Uninsured Boaters
Medical Payments
Personal Effects
Comprehensive Deductible
Collision Deductible
Towing
Other Coverage Information
Homeowners Insurance Carrier
Umbrella Insurance Carrier
Auto Insurance Carrier
Any Additional Comments
- By Checking this Box, you certify that all information provided is accurate.*
Are you currently a client of IRMS?*
If yes, who is your agent?*
If no, have you spoken to any of the following agents?*
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