Boat, Yacht & Jet Ski
Insurance Request Form
Pennsylvania
If you live outside of Pennsylvania

To receive a quote, please fill out the form below.....
Name:
Address:
City, State, Zip:
Phone Number (home & cell):
E-Mail Address:
Current Carrier Information and Expiration date of policy?
Current Insurance Company Name: Expiration date:
Liability Limits.....
Property Coverages Information...
Deductible Boat Length Type Weight of Boat Speed
feet   lbs Max. Speed: mph
YEAR MAKE/MODEL HULL WHERE IS THE BOAT USED INSURED
VALUE
BOAT $
MOTOR Horse Power:   Fuel: $ 
Storage Location:
                           Please provide "HOME", marina & address or other storage location		 Trailer: $ Accessories...:$

Safety Equipment
Built-in CO2 Fire Extinguisher Radar Equipment VHF Ship-to-Shore Radio Electronic Burglar Alarm
Loran or GPS Vapor Detection System Depth Finder Outdrive Lock

Driver Information...
Driver Name BirthDate Gender Marital Status License# Years Licensed
(Automobile)		 Boating Experience
(# of years)
# 1 
Safety Courses:  Yes  / No     Date of Safety Course:
Driver Name BirthDate Gender Marital Status License# Years Licensed
(Automobile)		 Boating Experience
(# of years)
# 2 
Safety Courses:  Yes  / No    Date of Safety Course:
Driver Name BirthDate Gender Marital Status License# Years Licensed
(Automobile)		 Boating Experience
(# of years)
# 3 
Safety Courses:  Yes  / No    Date of Safety Course:
Driver Name BirthDate Gender Marital Status License# Years Licensed
(Automobile)		 Boating Experience
(# of years)
# 4 
Safety Courses:  Yes  / No    Date of Safety Course:

Accidents and Violations....
Does any driver have any accidents or violations in the last 3 years?   Yes     No

If YES, Please list ANY violations or accidents within last 3 years.......
DATE DRIVER NAME TYPE OF OCCURRENCE
1 
2 
3 
4 

Which association do you belong? 
 
 

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474           Fax: (724) 327-7911
Toll Free: 1-800-977-2999     Fax: 1-888-800-0034
www.McGrathInsuranceGroup.com          McGrathInsurance@aol.com