Watercraft Insurance Form

Please complete as much of this form as possible.
Full Name*	A value is required.
Birth Date*	- mm/dd/yyyy A value is required.Invalid format.
Social Security Number*	Your social security number can be submitted over the phone by calling 570-226-4571 and asking for a Personal Agent.
Spouse/Partner Full Name
Birth Date	- mm/dd/yyyy Invalid format.
Social Security Number	Your social security number can be submitted over the phone by calling 570-226-4571 and asking for a Personal Agent.
Email Address*
Additional Email Address
Home Phone*	A value is required.
Work Phone
Resident Address*	A value is required.

Driver Information
Drivers 1 information state issued, license number
Driver 2 information state issued, license number
Driver 3 information state issued, license number
Driver 4 information state issued, license number

Watercraft Information (Required)
Who is the primary operator of this watercraft?
Year*	A value is required.
Make*	A value is required.
Model*	A value is required.
Hull ID Number*	A value is required.
What is the current value or purchase price?*	A value is required.

Additional Watercraft Information (optional)
Length of the watercraft:	ft.
Hull Material:	Fiberglass Aluminum Inflatable Other
Propulsion Type:	Inboard Outboard Inboard/Outboard
Maximum Speed:	mph
Mooring Zip Code (if different from home zip code):
Approximate value of the watercraft:

Watercraft Motor Information
Year (if different from boat):
Make (if different from boat):
Horsepower:

Trailer Information
Is there a trailer?:	Yes No
If yes, what is the year:
If yes, what is the make:

If the following information is not known, please leave blank.
Comprehensive Deductibles	$100 $250 $500 $1000
Collision Deductibles	$100 $250 $500 $1000
Liability Limits	100/300/50 250/500/100 Single limit 100,000 Single limit 300,000 Single limit 500,000

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