Lakewood Financial

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Boat Insurance Request Form

Information

Please be sure to complete all of the requested information
so that your agent may contact you after receiving this notification.

Named Insured:

Address:

City:

State:

Zip:

Day Phone:

Cell Phone:

E-mail Address:

Best Time To Contact:

AM PM

Method of contact:

Current Policy Information

Insurance Company:

Policy Expiration Date:

Coverage's
(input desired coverage's)

Type	Amounts
Hull Value	$
Liability Coverage	$
Trailer Value	$
Personal Property	$
Medical Payments	$
Towing	$

Vessel Information

Manufacturer/Model:

Year:

Length:

Date Purchased:

Purchase Price:

Max Speed:

mph

Location of Vessel:

Waters navigated:

Miscellaneous
(please check ALL that apply)

Trailer Information

Year:

Date Purchased:

Purchase Price:

Present Value:

Manufacturer/Model:

Operators

#	Name	DOB	Auto DL #	State
1
2
3
#	Auto Violations/Suspensions in last 5 years:				Years of Boating Experience:
1
2
3

Additional Information Section

In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverage's engines, etc.

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.