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Jet Ski 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		* Phone Number
Work Phone		Fax Phone

Driver Information - Please list all drivers
	Name	Date of Birth	State Lic. In	Gender
Driver 1
Driver 2

	Marital Status	Years Licensed	Citations past 3 years	Accidents past 3 years	Major violations past 3 years
Driver 1
Driver 2
List the dates of any citations or accidents on all drivers:
Years of Boating Experience (Ex: 10 years)			Driver 1 Driver 2

Jet Ski Information
PWC	Make If "other", specify	Model	Year	Length
1				Ex -- 16 feet. Most jet
2				Skis are 8-9' in length.

PWC	Total Horsepower	Total CC's	Value	New / Used
1
2

Coverages Offered
Bodily Injury/Property Damage Liability (Note: CSL = combined single limit liability)
Uninsured Boater (Optional Coverage)
Medical Payments
Personal Effects
OTC Other Than Collision (Deductible)
Collision (Deductible)
Is your trailer included in the value?

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OTHER:
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phone email	fax mail

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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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To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W. Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

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