Michael W. Smith Agency

Michael W. Smith Agency Logo

Home Up News Feedback Links

Jet Ski

If you live outside of Minnesota click on the Agency Link System

Agency Link System

horizontal rule

-

This is a request for a Minnesota jet ski quote, not a policy application. Submitting this form does not obligate you to purchase any personal watercraft insurance products. Please complete this form as accurately as possible. Jet ski insurance rates are subject to change.


General Information

Name
Street
City, State ZIP      
E-mail
Phone
FAX

Residence Information

Primary Residence
Months at Address

horizontal rule

Current Jet Ski Insurance Information

Current Insurance Co.

Expiration Date

horizontal rule

Operator Information (please list all Operators)

Driver #1
Name Birthdate Sex Marital Status Years  Experience
 

Number of Accidents (Last 5 Years)

Comment on Accidents (Date, Fault, Amount)

Number of Violations (Last 5 Years)

Comment on Violations (Date, Violation Type)

horizontal rule

Driver #2
Name Birthdate Sex Marital Status Years  Experience
Number of Accidents (Last 5 Years) Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years) Comment on Violations (Date, Violation Type)

horizontal rule

Percentage of Use

  Driver 1. Driver 2.
Snowmobile 1.
Snowmobile 2.

horizontal rule

Jet Ski Information

Watercraft Unit 1.
Year Make Model Number of CC's Length
Horsepower Maximum Speed Storage Years Owned Value
Weight Describe Any Accessories/Special Equipment Including Cost When New

horizontal rule

Watercraft Unit 2.
Year Make Model Number of CC's Length
Horsepower Maximum Speed Storage Years Owned Value
Weight Describe Any Accessories/Special Equipment Including Cost When New

horizontal rule

Trailer Information

Year Make Model Value

horizontal rule

Coverage's

Liability Coverage. Pays for other people's injuries and damage to their property if you or someone else cause an accident while driving your watercraft. It protects your assets in the event you are held liable for damage to others.

Bodily Injury Liability Comment
Property Damage Liability

horizontal rule

Medical Expense Coverage. If you and your passengers are injured in an watercraft accident, this coverage pays your medical expenses.
Medical Expense Comment

horizontal rule

Uninsured and Underinsured Operators Coverage. Pays bodily injury claims if you or your passengers are injured by a negligent uninsured operator, hit-and-run operator or a negligent operator without adequate insurance.
Uninsured/Underinsured
Comment

horizontal rule

Comprehensive Coverage. Pays for damage to your watercraft caused by theft, fire, windstorm, vandalism and many other non-collision occurrences.
Collision Coverage. If your watercraft collides with another watercraft or object, this coverage pays to repair your watercraft.

  Unit 1. Unit 2. Trailer

Comprehensive Deductible

Collision Deductible

horizontal rule

Comments

horizontal rule

[Home] [Up]
Number of hits since August 15, 1998

Send mail to mwsmith@visi.com with questions or comments about this web site.

Since 1978
Michael W. Smith Agency

Copyright © 2000 Michael W. Smith Agency
Last modified: April 06, 2008