Jet Ski Insurance - Under 16ft

Personal Watercraft Application L.O.B. 82

For Underwriting Guidelines Click Here

Label

POLICY TERM

Requested Effective Date

Prior Carrier

Exp. Date

NAMED INSURED

First Name

M.I.

Last Name

Telephone Number (Area Code)

Address

City

State

County

Zip

Email Address

Fax #

LIEN HOLDER - FINANCING

Lien Name

Loan#

Address

City

State

Zip

AGENT-PRODUCER

Agent -Tx License Number

Agency Name

Phone No. (incl. Area Code)

Address

City

State

Zip

ALL HOUSEHOLD RESIDENTS OVER 15 - OTHER OPERATORS UNDER AGE 15 (Use Remarks section below if needed)

Name(s)

BIRTH DATE
MM/DD/YYYY

SOCIAL SECURITY #
000-00-0000

AUTOMOBILE
DRIVERS LICENSE
NUMBER

STATE
ISSUING
LICENSE

% OF USE

MARITAL
STATUS

MOTOR
VEHICLE
ACCIDENT(S)

MOTOR
VEHICLE
VIOLATION(S)

PRIOR
LOSSES

Explain any "YES" answers:

OPERATOR REQUIREMENTS
No more than five (5) Minor violations in the last 3 years.

***DESCRIPTION OF PERSONAL WATERCRAFT - Not to exceed 16 feet in length!

Serial Number

Type(s)

Year

CC's

Make/Model

Date Purchased

**Purchase Price

**Actual cash value policy

***Insures only stock manufactured watercraft

DESCRIPTION OF TRAILER(S)

Serial Number

Year

Make/Model

Purchase Price

COVERAGES

COVERAGE LIMITS

Watercraft Liability

Includes Watersport Coverage

Uninsured Boat Owners

Medical Payments

Physical Damage Coverage(ACV)

deductible options

theft deductible

Accessories

(limit for all units)

$100 deductible

($100 - $5,000 Limit)

Number of Trailers

$250 deductible

Min. Written and Earned Premium $100

Discounts that apply:

Transfer: The applicant has maintained continuous, claim free, insurance on a watercraft for the past year.

Claim Free Renewal: (If watercraft is insured with American Reliable or another company with the General Agent and Claim Free past for the past 12 months)

Multi-Unit (Applied when insured has more than 1 Personal Watercraft insured with American Reliable)

INSTALLMENT BILLING OPTIONS

Full Pay 100% Down Two Pay 50% Down Four Pay 25% Down

REMARKS / COMMENTS

Producer's Name

Agent License #

DISCLOSURES / SIGNATURES

FAIR CREDIT REPORTING ACT NOTICE: In compliance with the Federal Credit Reporting Act (Public Law 91-508), you are advised that the Company may order reports, which may contain or include information pertaining to the character, general reputation, personal characteristic, and mode of living of the applicant and/or other drivers listed in this application. Upon written request, the complete nature and scope of the investigation will be provided.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claims containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may subject such person to criminal and civil penalties.

PRIVACY POLICY: I have received and read a copy of the American Reliable Insurance Company/Assurant Group Privacy Policy. By submitting this application, I am applying for insurance and, at its expiration, for appropriate renewal policies issued by American Reliable Insurance Company. I understand and agree that any information about me that is contained in, or that is obtained in connection with, this application of any policy issued to me may be used by American Reliable Insurance Company to issue, review, and renew the insurance for which I am applying.

I hereby declare to the best of my knowledge and belief that all of the foregoing statements are true and these statements are offered as an inducement to the Company to issue the policy for which I am applying. I understand this policy may be cancelled if this application contains any false statement, omission, or material misrepresentation that would have otherwise altered the company's evaluation of the named insured. I understand that motor vehicle records may be verified.

Insured's E-Signature (Enter Full Name Of Person Who Completed Above Application )

Date Above Application Completed

American Reliable Insurance Company Policy Forms Are Mailed , Emailed , or Faxed Along With Each Quote We Provide

Note: These Sample Policy Forms Represent Current American Reliable Insurance Company Personal Watercraft Policy Forms

Coverage proposals presented to you by our Agency may differ; as each insurer represented may offer modified coverage by endorsement or have filed it's own unique policy forms with the Texas Department Of Insurance. Please carefully read any carrier prepared proposal presented to you and where necessary request a copy of each insurance company policy and endorsement form presented; so that you may compare any differences in coverage offered.

For Underwriting Guidelines Click Here