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8500 Shawnee Mission Pkwy,
Suite 200,
Merriam, KS 66202
877-812-8216

The Bristol Gold Watercraft Insurance Policy

Quote

Applicant Information

Name: *
Date of Birth: *
How did you hear about us? *
Address
Address2
City, State, Zip:
Phone:
Email: *
Are you a 6-pack Fishing Charter? *
1. YesNo

Watercraft Information

Year *, Manufacturer *, Model *
Length * ft. in.
Beam
Hull Material
1. FiberglassAluminumWood
Type *
1. BassboatRunaboutPontoonDeckboat
  WalleyeOther*
* If Other, please explain
Engine #1 * Make Model Year HP
Engine #2 Make Model Year HP
Engine Type *
1. OutboardInboardI/OWater JetNone
Trailer * Year Make
Trolling Motor Lbs. of Thrust Make Model Year
Equipment
1. Depth/Fish FinderStainless Prop
  GPSAnti-Theft Trailer
  Anti-Theft BoatAnti-Theft Prop
  VHF RadioVapor Detector
  Auto Halon/CO2
Purchase Date *
Total Purchase Price *

Operator's Experience

Total years of boat ownership * Total years of operating experience *
Licenses Held
Previously owned boats Make Model HP Years Owned
Previously owned boats 2 Make Model HP Years Owned
Previously owned boats 3 Make Model HP Years Owned
Boating Courses Completed & Year
Any Auto or Watercraft Losses? *
1. YesNo
If yes: Date Circumstances $ Amt. Paid
Losses 2 Date Circumstances $ Amt. Paid
Losses 3 Date Circumstances $ Amt. Paid
Any Auto or Watercraft Violations
or Suspensions? *
1. YesNo
If yes: Date Circumstances
Violations 2 Date Circumstances
Violations 3 Date Circumstances

Intended Use

Waters Navigated *
1. InlandGreat LakesCoastal
  Chesapeake Bay onlyOther* (details)
* If Other, please explain
State where vessel is kept * Zip *

Coverage Desired

Hull & Equipment $
O/B Motor #1 $
O/B Motor #2 $
Trailer $
Trolling Motor $
Personal Effects $
($1000 included)
Watercraft Liability *
1. $50,000$100,000$300,000$500,000
Deductible *
1. $100$250 (standard)$500$1000

Choose only one(1) *
1. Disappearing Deductible OR10% Annual "Claims-Free Discount" At Renewal

Optional Coverage

Optional Coverage
1. Bristol Gold Plus What's this?
  Contaminate/Fuel Spill Coverage What's this?
  NAVIGUARD™ MBI What's this?
  Total Replacement Cost Coverage What's this?
  (watercraft may only be five(5) model years old or newer!)

Current Insurance

Issuing Company Exp. Date
Current/Renewal Premium $
Has vessel been continuously
insured for the past 12 months?
1. YesNo
If "No", please explain

Products
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Submit a Claim
- Property Claim
- Injury Claim
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- Personnel List
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