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KELLEY
INSURANCE AGENCY
& FINANCIAL SERVICES, INC.
103 West Main Street
P.O. Box 367
Everson, WA 98247
Whatcom County, USA
(360) 966-3732
Fax: 360.966.2819
Kelley Insurance Agency
& Financial Services, Inc.
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Boat Quote
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First Name
*
Last Name
*
Mailing Address
Phone
*
Email
Date of Birth
Social Security
Marital Status
Single
Married
Separated
Divorced
Other
Have you had any tickets or accidents?
No
Yes
If so What and When:
Boat Year, Make, & Model
Number of Motors
1
2
3
4
5
More than 5
Motor, Year, Make, & Model
Hull Material
Fiberglass
Aluminum
Inflatable
Wood
Steel
Other
Propulsion Type
None
Outboard
Inboard/Outboard
Inboard
Jet
Power
Other
Maximum Speed
Horsepower
Boat Value
Motor Value
Trailer Value
Do you currently have boat insurance:
Yes
No
Waters Navigated
Lakes
Rivers
Ocean
Other
Boat Storage
Personal Garage
Marina
Other
Would you like to add another Driver:
Yes
No
Name
Date of Birth
Relationship
Spouse
Child
Parent
Other
Any tickets or accidents
No
Yes
If so what and when
Bodily Injury/Property Damage
50/100/50
100/300/100
300CSL
250/500/100
500CSL
Other
Personal Injury Protection
10,000
35,000
Underinsured Motorist
50/100/50
100/300/100
300CLS
250/500/100
500CSL
Other
Comprehensive Deductible
100
250
500
1000
2000
Collision Deductible
100
250
500
1000
2000
Towing
Yes
No
Access Code
Please Enter the Access Code
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Kelley Insurance Agency, Inc.
103 West Main Street | P.O. Box 367 | Everson, WA 98247 | Whatcom County | USA
360.966.3732
| Fax: 360.966.2819
www.kelleyinsure.com
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