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Watercraft Quote Request Form - (Texas Residents Only!)

(* Indicates a required field)

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

Insured Name:

*Full Name: *SSN # (ie;999-99-9999) *DOB: (MM/DD/YYYY)

*Mailing Address: City: State: Zip:

*Contact Phone: Cell # *Email: (EIA use only)
Referred by:

Year:
Make:
Model:
Hull Material:
Number of Motors:
Propulsion Type:

Does the boat have an exposed engine:
Modified for Enhanced Performance:
Maximum Speed:

Rating Base:
Rating Base includes trailer:
Storage / Mooring Zip Code:
Watercraft Use:
Multi-Owner:
Primary Residence:
Physical Damage Coverage:
Comprehensive Deductible:
Collision Deductible:
Bodily Injury / Property Damage � Liability Limits:
Uninsured Boater:
Guest Medical Payment:
Replacement Cost of Personal Items:
On Water Towing:
Waterways Boat will be Navigated in:
Fishing Equipment Coverage:
How many months a year is the boat laid up (on trailer):

Comments/Remarks:

Submission of quote request form to Elzey Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage. To confirm binding or policy revision you must receive verbal or written confirmation from a licensed E.I.A. representative.

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