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Utah insurance quotes from the Sergakis Agency

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Sergakis Insurance Agency
8300 S. 700 E., Suite 200
Sandy, UT 84070
Phone: 801-432-2100
Toll Free: 800-928-8175
Fax: 801-432-2101

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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 Utah)
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:
(M/F):		# Years U.S. Licensing:
Be specific to tell if s are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault s); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of s last 3 years:		Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:		Number of Years Boating Experience:

OPERATOR INFORMATION #2 (if none, leave blank)
Name:		Birthdate:
:		# Years U.S. Licensing:
Be specific to tell if s are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault s); Also, be specific as to TYPE of violations in fields below:
Number & Type of s last 3 years:		Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:		Number of Years Boating Experience:

VESSEL & UNDERWRITING INFORMATION
Year of Boat:		Make & (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 $250/500 BI / 100 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)

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