New York Insurance by Bermack, Champion & Lewine for Auto, Homeowners, Business and Personal Insurance
This website offers services primarily to current and future residents of NY, CT and NJ.
14 Penn Plaza, Suite 1611, New York NY 10122, Tel. (212) 239-1140  
 
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Watercraft Quote
This Quote is for NY, CT and NJ only
This quote form applies to both JetSkis and Boats. All questions refer to both types of watercraft unless otherwise indicated. Blue sections refer to Boats and Red sections to JetSkis. If you are requesting a JetSki Quote, you may skip over the Boat sections by clicking the "Skip" button at the top of the Boat sections.
Named Insured
Name:
Address:
City/State/Zip: / /
Phone:
Fax:
Email:
Preferred Response Method:
Watercraft Type
This quote request is for a: BOAT JETSKI
Operator Information
Name: User 1
User 2
User 3
User 4
Date of Birth: User 1
User 2
User 3
User 4
Drivers License #:
User 1
User 2
User 3
User 4
License State of Issue: User 1
User 2
User 3
User 4
Years Watercraft Experience: User 1
User 2
User 3
User 4
Minor Violations Last 3 Years: (List Month/Year for each incident.)
   "mm/yyyy, mm/yyyy,.."
User 1
User 2
User 3
User 4
Major Violations Last 3 Years: (List Month/Year for each incident.)
   "mm/yyyy, mm/yyyy,.."
User 1
User 2
User 3
User 4
At-Fault Accidents Last 3 Years: (List Month/Year for each incident.)
   "mm/yyyy, mm/yyyy,.."
User 1
User 2
User 3
User 4
Description of Watercraft
Year:
Make:
Model:
Serial #:
Max HP (Boats) or CC (JetSkis) "## HP" or "## CC"
Length: feet
Max Speed: mph
New/Used New Used
Registration #: (Boats)
1,2 or 3 Passenger: (JetSkis)
State of Navigation:
Purchase Date: "mm/dd/yyyy"
Purchase Price: $
Describe any permanently installed or custom equipment:
      Description of Motors (Boats)
Year: Motor #1
Motor #2
Make: Motor #1
Motor #2
Serial #: Motor #1
Motor #2
HP: Motor #1
Motor #2
Year Rebuilt:
(if applicable)
Motor #1
Motor #2
Description of Trailer(s)
Year:      "yyyy, yyyy, ..."
Make:     "make, make, ..."
Serial #:   "##, ## ..."
    Additional Items On Board Boat
Miscellaneous Equipment:
"Item Description, $ Value, Item Description, $ Value, ..."
Personal Effects:
"Item Description, $ Value, Item Description, $ Value, ..."
Detailed Boat Information
Boat Type:
   Other
Boat Construction:
   Other
Area of Navigation: Inland Waters
Great Lakes
Gulf Coastal < 3 Miles
Gulf Coastal 3-25 Miles
Atlantic Coastal < 3 Miles 
Atlantic Coastal 3-25 Miles
Pacific Coastal < 3 Miles
Pacific Coastal 3-25 Miles
SanFancisco Bay (not west of                                              Golden Gate)
Lake Powell/Mead

Is extended coastal navigation desired?
Garaging/Mooring During Period of Use:
Other
Garaging/Mooring During Lay Up:
Other
Watercraft Losses in Last 3 Years
Date of Loss: Loss 1 "mm/dd/yyyy"
Loss 2 "mm/dd/yyyy"
Loss 3 "mm/dd/yyyy"
Cause of Loss: Loss 1
Loss 2
Loss 3
Describe damage to watercraft and equipment: Loss 1
Loss 2
Loss 3
Was anyone injured? Please explain: Loss 1
Loss 2
Loss 3
$ Amount of Damage: Loss 1 $
Loss 2 $
Loss 3 $
      General Boat Information
In what state is the boat primarily navigated?
How many years has the principal operator maintained and operated a watercraft?
Has engine been turbocharged, supercharged, altered or modified in any way for the purpose of enhancing speed or performance?
Is this boat the primary residence of the insured?
Is this boat titled in the name of or used in the course of the insured's business?
Note: Coverage is limited to private pleasure use of owner.
Is this boat owned by others in addition to the named insured?
Note: Maximum of three owners for coverage eligibility.
Is craft permanently moored?
If yes, Where (Including Zip Code)
Is this boat currently for sale by the insured?
Is the insured boat used for water-skiing? (power boats only)
If yes, is water-skiing liability coverage desired?
Has the principal operator of the boat completed either the US Coast Guard Auxiliary or US Power Squadron introductory courses? (Completion Certificate will be required)
Is your motor's propeller construction other than stainless steel?
General JetSki Information
Is personal watercraft modified in any way to enhance speed or performance? If yes, please explain.
Is personal watercraft used in any race or exhibition?
Please Note - No coverage for race or exhibition.
Is personal watercraft titled in the name of or used in the course of the insured's business?
Note: Coverage is limited to private pleasure use of owner.
Is personal watercraft currently held for sale and if so, how long has it been for sale?
Where will personal watercraft be stored when not in use? (Including Zip Code)
Thank You. You have completed the form. Add any general comments in the box below, then click the "Submit" button. We will respond to you promptly. Thank you for considering Bermack, Champion & Lewine for your insurance needs.
Comments:

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