Jackson Insurance Quote Sheet

*Name: *Day Phone:

*Address: Home Phone:

*City, State, Zip:

*Date of Birth: *Yrs. Operating Experience (for marine):

*Any Losses? Yes No

If yes, describe:

*Boating and/or Driving Courses Complete:

*Moving Violations: No Yes

If yes explain:

VEHICLE INFORMATION: Purchase Date (or approx date of settlement):

*Vehicle Mfg.:

*Length (if applies) & Model: *Model Year:

*Choose:

Gas Diesel Horsepower each:

* For Watercraft:

I/O I/B O/B Jet No. Engines: Max. Speed:

*Docking Location (ie Home on trailer, Marina, Hi/Dry etc.)

Area of Navigation: If other explain:

Have Survey? Yes No If yes, date:

* Vehicle Type:

Check all that applies:

VHF DF Radar Loran Halon Fume Det. CO Det.

Special Equipment:

*Value: *Deductible: *Liability:

Additional Operators:

Present Premium: (if any)

* This information is necessary for quoting.

We will contact you as soon as possible with your quote. Any questions please call 410-287-9400 x 247 or email quote@jacksonmarinesales.com