JOHNSON & BRYAN - Insurance Brokerage and Risk Management

Driver Name

Date of
Birth

Marital
Status

Occupation

Years of
Boating
Experience

Boat Insurance Quotation Request
Georgia Residents Only

For the fastest and most accurate quote, please provide as much information as
possible in the form below. This information will be kept confidential and will be used for
quote purposes ONLY!

Note: BOLD indicates required field

Name:
Address:
City:	State: Zip:
County:	(not country)
Day Phone:	Fax:
E-mail:

Boat Description

Boat	Year	Make & Model Please Be Specific	Vehicle ID# Enables Quote Accuracy	Type of Boat	Value
1
2

Boat	Boat Construction	Horsepower or cc	Length	Weight	Main Engine	Waters Navigated	Maximum Speed
1
2
		cc's req'd for Jet Skis

Driver Information

Please list all violations and accidents (including not-at fault accidents) for the last 5 years:

Liability / Uninsured Motorists / Medical Payments

Liability Limit - Bodily Injury
Liability Limit - Property Damage

Uninsured/Underinsured Motorists Limit
Uninsured/Underinsured Motorists Property Damage

Medical Payments - Per Person Limit

Physical Damage Coverage & Deductibles

Boat	Comprehesive Deductible	Collision Deductible
1
2

Additional Information

Do you currently have insurance? Yes No
Who is you current boat insurance company?
When does your current policy expire?
Current Premium every