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* Required Fields

General Information

First Name * MI Last Name*

Street Address *

City* State Zip Code*

Phone - - Email Address*

Driver Information
Driver #	Driver Name*		Birth date* (dd/mm/yy)	Gender*	Marital Status *	Drivers License Number/State
1)				M F	Married Single
2)				M F	Married Single

Watercraft Information
Year*	Make*	Model		Value*	Style*		Length (ft)*	Material*
					Sailboat I/O Outboard Wave Runner Cabin Cruiser			Fiberglass Aluminum Wood

Engine Information
Year*	Make	Value*	Horsepower*	Maximum Speed (mph) *

Waters Navigated
Great Lakes	Chain of Lakes	Other Inland Lakes/Rivers

Coverage Information
Liability $100,000/$300,000/$100,000 $250,000/$500,000/$100,000 $50,000/$100,000/$50,000 $20,000/$40,000/$15,000		Medical Payments $5,000 $10,000 $1,000	Deductible* $250 $500 $100 No Coverage
Claims History
Have you filed any claims, been involved in any accidents including not-at-fault, or received any moving citations within the last 5 years? Yes No If yes, please list below.
Driver #	Date	Incident Type	Description	Amount Paid
1 2		At Fault Accident Not At Fault Accident Other Claim Moving Violation
1 2		At Fault Accident Not At Fault Accident Other Claim Moving Violation
Current Insurance Information
Insurance Company*			Expiration Date
Remarks

Insurance quotations are determined using consumer reports and claims/driver history. By submitting this request, you authorize Faller Insurance Agency to order your consumer report. The quotation you will receive will be based on this report along with the claims/driver information you provide us. For an accurate quotation, it is important that you provide us with information pertaining to all claims, including "not at fault" accidents.