Florida Boat and Yacht Insurance - low cost coverage and high priced service!

Vista Healthplan, Inc.

Thanks for using our services!

© 2004 J.A. MESSINA INSURANCE
PO Box 244571
Boynton Beach, FL 33424-4571
Phone: 561-736-2162
Fax: 561-736-0228
License#A177282
E-Mail us at:
jamessinains@comcast.net

For Your Convenience,
We gladly accept:

"All Our Policies Come With
an Agent!"

Need Coverage TODAY? After Submitting
Your Quote Form (see below), Call Toll-Free:
1-800-735-2162
(Monday-Friday 9:00am-5:00pm Florida local time)

On-Line Boat & Jet Ski
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!

Your Personal Data

Your Name:

Street Address:

City:

State: MUST be Florida!

Zip Code:

E-Mail (REQUIRED):

E-Mail again for accuracy:

Phone:

Fax (optional):

Marital Status:
Single Married
Homeowner?
Yes No

Boat Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)

Is this Boat Co-owned?
(If yes, list all owners names)

OPERATOR INFORMATION #1

Name: Birthdate:

Sex (M/F): # Years U.S.
Licensing:

Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:

Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:

Number & Type of MAJOR Cites last 3 years: Number of Years
Boating Experience:

OPERATOR INFORMATION #2 (if none, leave blank)

Name: Birthdate:

Sex: # Years U.S.
Licensing:

Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:

Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:

Number & Type of MAJOR Cites last 3 years: Number of Years
Boating Experience:

VESSEL & UNDERWRITING INFORMATION

Year of Boat: Make & Model
(be specific):

Boat Length: Hull Type
(wood, Metal,
fiberglass, etc):

Max. Speed
(in MPH): Market Value: $

Engine Make: Engine Type:
(Inboard, I/O, Jet)

Engine Horse
Power: Fuel Type:
(Gas, Diesel, etc.)

Trailer Cov.
Needed? Yes No Yr./Make/Model
of Trailer:

Trailer Value: $ Where is boat
moored or stored?

Describe waters
boat taken on? Describe boat
general usage?
(fishing, ski, etc.)

VESSEL COVERAGES:

Limits of
Liability: $15/30 BI / 10 PD $25/50 BI / 15 PD
$50/100 BI / 25 PD $100/300 BI / 50 PD

Hull Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Water Ski
Medical Coverage? Yes No Uninsured
Motorists Cov.? Yes No

Comments or Remarks:
(List additional drivers,
special coverages, etc. here)

Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone!

Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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