Nicholson and Associates Insurance

Contact Information and Information About You

First Name:*

Last Name:*

Date of Birth:*

Social Security Number:

Drivers License #:*

Email Address:*

Phone Number:*

Address 1:*

Address 2:

City:*

State:*

Zip Code:*

Current insurance company, if any:

Approximate current premium:

Information About Your Boat

Type of Boat:*

Year:*

Make:*

Model:*

Hull length:*

Type of Power:*

Hull Material:*

Engine Manufacturer and Model:

Engine horsepower:

Maximum Speed:

Approximate Value:

Please list any additional equipment (GPS, Radar, Loran)

Make of prior vessels:

Summer Mooring Name and Address:

Winter Mooring Name and Address:

Information About the Boat Operator(s)

Please list the name and the age of any additional boat operators:

Please list the years boating experience for all operators. Please detail: type, length and time used for each operator.

Do any operators have motor vehicle citations in the last 3 years?

Yes No

If yes, please describe:

Do you have any comments or questions we can help with?

Binding Agreement

(Required) I understand that any policy changes and quote requests are effective only when I have received a written confirmation.*

I agree

SMS Opt In

By submitting this form and signing up for texts, you consent to receive text messages from Nicholson & Associates Insurance LLC at the number provided, including automated messages and messages related to Customer Care. Consent is not a condition of purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP or clicking the unsubscribe link (where available). Reply HELP for help. Privacy Policy & Terms *

Yes No

File Upload

If you have any documents to upload and attach to this form. Please upload them here: (Optional):

Click here to attach a file to this form

*Required fields:

This submission is a request. Insurance coverage changes and new coverages are not effective until we confirm that for you.

We will do our best to furnish a quote based on the information you provide. The more complete your information, the more accurate your quote will be.

Security:
The security of your personal information is important to Nicholson and Associates Insurance. Our site uses SSL encryption to ensure your personal information is sent securly to us.

Boat and Watercraft Quote Request