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    Minnesota Insurance Center.com
    PO Box 1177 Lakeville, MN 55044
    Phone: 952-469-0425 | Fax: 952-469-1881
    Email Us Your Questions: Customer Service
    • On-Line Boat & Jet Ski
    Insurance Quote Form
    One Simple Form - takes only 2-3 Minutes!
    Your Personal Data

    Your Name:
    Street Address:
    City:
    State: (Must be Minnesota)
    Zip Code:
    E-Mail (REQUIRED):
    E-Mail again for accuracy:
    Phone:
    Fax (optional):
     
    Marital Status:
    Single Married
    		Homeowner?
    Yes No
     
    Boat Currently Insured?
    (If yes, list carrier, and # of years
    continuous. If none, type N/C)
     
    Is this Boat Co-owned?
    (If yes, list all owners names)

    OPERATOR INFORMATION #1
    Name: Birthdate:
    Sex (M/F): # Years U.S.
     Licensing:
    Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
    Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
    Number & Type of MAJOR violations last 3 years: Number of Years
    Boating Experience:

    OPERATOR INFORMATION #2 (if none, leave blank)
    Name: Birthdate:
    Sex: # Years U.S.
     Licensing:
    Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
    Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
    Number & Type of MAJOR violations last 3 years: Number of Years
    Boating Experience:

    VESSEL & UNDERWRITING INFORMATION
    Year of Boat: Make & Model
    (be specific):
     
    Boat Length: Hull Type
    (wood, Metal,
    fiberglass, etc):
     
    Max. Speed
    (in MPH):    		 Market Value: $
     
    Engine Make: Engine Type:
    (Inboard, I/O, Jet)
     
    Engine Horse
    Power:    		 Fuel Type:
    (Gas, Diesel, etc.)
     
    Trailer Cov.
    Needed?    		 Yes No Yr./Make/Model
    of Trailer:
     
    Trailer Value: $ Where is boat
    moored or stored?
     
    Describe waters
    boat taken on?    		 Describe boat
    general usage?
    (fishing, ski, etc.)

    VESSEL COVERAGES:
    Limits of
    Liability:    		 $15/30 BI / 10 PD $25/50 BI / 15 PD
    $50/100 BI / 25 PD $100/300 BI / 50 PD
    $250/500 BI / 100 PD
     
    Hull Coverage: NO Coverage $250 Deductible
    $500 Deductible $1000 Deductible
     
    Water Ski
    Medical Coverage?    		 Yes No   Uninsured
      Motorists Cov.?    		 Yes No
     
    Comments or Remarks:
    (List additional drivers,
    special coverages, etc. here)

    Send my quotation via: E-Mail Fax
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    Thank you for filling out this form COMPLETELY!

    We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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