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Boat Rate Request

Fields marked by an * are required.
For your quote to be of the highest accuracy, please complete all fields.

* Name		* E-mail
* Address		* City
* State		* Zip
County		Work Phone
* Phone Number		Fax Phone
Occupation

Driver Information
Driver	Name	Date of Birth	State Licensed in	Gender
1
2
	Marital Status	Citations past 3yrs	Accidents past 3 yrs	Major Violations past 3yrs
1
2

Boat Information

Year Model:	(example 1995)
Type of Boat:
Hull Material:
Boat Length:	(Example 18 feet)
Total Horsepower:
Type of Drive:
Boat Actual Current Cash Value:
Trailer Actual Current Cash Value:
Additional Accessories:
(depth finders, trolling motors, etc. Fishing Gear cannot be covered)

Coverage Desired

Coverage choice

Liability only
$50,000 Liability, $1000 Medical,
Comprehensive & Collision

Increase Medical Payments

Increase Liability Coverage

Deductible

Check the following if you:

	have taken an approved Safety Course.
	are a member of a boating association / marina membership.

* Where did you hear about our site?

OTHER:
(if it's a link, please be specific)

Please select the most convenient method of contacting you:
phone email	fax mail

© 2009 MOCrop Insurance | Burgher Insurance
MOCrop Insurance & Burgher Insurance are equal opportunity providers. All rights reserved.

2709 E Liberty | Mexico | MO 65265
Toll Free: 1.800.633.6540
Tel: 573.581.4420 | Fax: 573.581.7264

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