Brooks-Cairns Insurance Group - Quotes

emails@brooks-cairns.com

Please be sure to include your name and policy number.

Boat Insurance Quote

We would like to provide you with a free, no-obligation boat insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Personal Information
Name:
Address:
Social Security Number:
City:
State:
Zip:
Day Phone:
Night Phone:
Best Time To Call:	AM PM
Email Address:

Current Auto Insurance Information
Company Name: (not agency)
Policy Expiration Date:
Premium Amount:
Term:	6 month 1 Year Other

Vessel Information
Include all boats you or your family members own or lease.
Boat #1
Year:
Make:
Model:
Vessel ID Number:
Registered Owner:
If boat is kept at address other than that listed above, please indicate below
Location City:
State:
Zip:

Boat #2
Year:
Make:
Model:
Vessel ID Number:
Registered Owner:
If boat is kept at address other than that listed above, please indicate below
Location City:
State:
Zip:

Liability Limit For ALL Boats
Choose either Bodily Injury and Property Damage Bodily Injury Property Damage	or Single Limit Single Limit

Deductibles and Misc.
Boat #	Comprehensive Deductible	Collision Deductible
1
2

Driver Information
Include all licensed drivers in your household.
Driver #1
Driver's Name:
Drivers License #:
License State:
Years Licensed:
Relation:
Date of Birth:
Sex:	Male Female
Marital Status	Married Single
Courses Completed Last 3 Years:	Drivers Ed: Y N Accident Prevention: Y N
Student Driver/GPA:	Check here if driver is a student with a 3.0 or higher grade point average.

Driver #2
Driver's Name:
Drivers License #:
License State:
Years Licensed:
Relation:
Date of Birth:
Sex:	Male Female
Marital Status	Married Single
Courses Completed Last 3 Years:	Drivers Ed: Y N Accident Prevention: Y N
Student Driver/GPA:	Check here if driver is a student with a 3.0 or higher grade point average.

Driver #3
Driver's Name:
Drivers License #:
License State:
Years Licensed:
Relation:
Date of Birth:
Sex:	Male Female
Marital Status	Married Single
Courses Completed Last 3 Years:	Drivers Ed: Y N Accident Prevention: Y N
Student Driver/GPA:	Check here if driver is a student with a 3.0 or higher grade point average.

Driver #4
Driver's Name:
Drivers License #:
License State:
Years Licensed:
Relation:
Date of Birth:
Sex:	Male Female
Marital Status	Married Single
Courses Completed Last 3 Years:	Drivers Ed: Y N Accident Prevention: Y N
Student Driver/GPA:	Check here if driver is a student with a 3.0 or higher grade point average.

Driver History
Please list any* convictions for any driver convicted of moving traffic violations in the past 3 years.*
Driver	Date	Type of Conviction	Fines	Speed Over Limit

Please list ANY driver who has had license suspensions, revocations or DUI convictions* below.*
Driver	License Suspended or Revoked	DUI Conviction for:
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs

Please list ANY driver involved in accidents, rgardless of fault, in the past 5 years.
Driver:	Date:
Description:	Cost:
Fines:	Injuries? Yes	At Fault? Yes

Driver:	Date:
Description:	Cost:
Fines:	Injuries? Yes	At Fault? Yes

Driver:	Date:
Description:	Cost:
Fines:	Injuries? Yes	At Fault? Yes

Driver:	Date:
Description:	Cost:
Fines:	Injuries? Yes	At Fault? Yes

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.

Please click on the "Submit Quote" button to send your
quote request.
One of our representatives will respond to your submission
as soon as possible.