* indicates required fields.

Required Effective Date: 07 / 02 / 2020
Agency Production Assignment Information
Subproducer Code:

Primary Insured/Driver 1
First Name:
MI:
Last Name:
Suffix:
Gender:
Marital Status:
Date of Birth:
OR
Age:
Age First Licensed:
Date Licensed:
When First Licensed?:
Social Security Number:
Permit Expiration Date:
Does person have own liability insurance?:
Insurance Company:

Residence Information
Current Address
Address:
Apartment:
Building:
PO Box:
RR #:
Suite:
City:
State:
Zip:
DBA:
Street:
City,Province:
Country:
Mailing Code:
Years At Current Address:
Previous Address
Country:
Address:
Apartment:
Building:
PO Box:
RR #:
Suite:
City:
State:
Zip:
DBA:
Street:
City,Province:
Country:
Mailing Code:

Contact Information
Type Phone Number Extension
Home:
Business:
Email Options:
Email:
Primary Residence:
Ownership Type:

Quote Mailing Address
Same As Current Address: YesNo
Country:
Address:
Apartment:
Building:
PO Box:
RR #:
Suite:
City:
State:
Zip:
DBA:
Street:
City,Province:
Country:
Mailing Code:

Other Insured Information
Qualifying Multi-Line Policies: NoneAutomobile
How long have the policies been in-force?:
Have any Drivers completed a Boating Education Course?: Yes No
Boating Education Course:
Organization Membership:

Primary Insured/Driver 1 Details
Name: MVR Status: Not Ordered
Accidents/Violations
Any Accidents/Violations in last 5 years?: Yes No
Violations < 3 Yrs 3-5 Yrs
Number of Minor Violations:
Number of Major Violations:
Number of Serious Violations:
Accidents < 1 Yr 1-2 Yrs 2-3 Yrs 3-5 Yrs
Number of At-Fault Accidents:
Number of Non Fault Accidents:
OR Declare Incidents Total Incidents is now based on Declared Incidents

License Information
State Licensed:
Driver's License Number:
Reason for Waiving MVR:

Current Insurance
Total Years of Boat Insurance with Prior Company or Length of No Need:
Reason for No Need:
Company Search:
Company:
Expiration Date:

Credit Report Information
Allstate Property & Casualty:
Is the location where boats are principally docked or stored the same as Current Address?: Yes No
Primary Docking/Storage Zip:
Boat Location:
Vehicle 1
Description
Year:
Make Search:
Make:
Model/Sub-Model:
Model:
Serial Number:
Boat Type:
Length:
Hull Construction:
Purchase Price:
Purchase Date:
Purchase Condition:
Present Value:
Power
Power Type:
Maximum Speed:  mph
Trailer
Include Trailer: Yes No
Year:
Make:
Serial Number:
Present Value:
Features
Homemade/Kit: Yes No
Performance Modifications: Yes No
Description:
Usage
Area of Use:
Usage Class:
Inspection
Marine Survey Completed: Yes No
Will you inspect the boat?: Yes No

Vehicle Limits/Deductibles Premiums
Premier Option:
Watercraft Liability:
Watercraft Medical Payments:
Your Property(Ded):
Repair Cost Option: Yes No
Uninsured Watercraft: Yes No
Boat Equipment: (Included Amount:$0)

Security Code *