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On-Line Marina Liability Insurance Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name:
Street Address:
City:
State:	MUST be California!
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:

MOORING & OTHER INFORMATION
Where is Your Boat Moored (give complete address)?:

Name and address of additional insured if required:


LIABILITY COVERAGES:
Limits of Liability:	$300,000 $500,000

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

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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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You may contact our agency at the address and phone numbers below:

Kostyo Insurance Agency
4456 Vandever Avenue, Suite 10 - San Diego, CA 92120
Phone: 1-619-325-3600 / Toll-Free: 1-888-567-6985
Fax: 1-619-325-3606 / Lic# 0B55791
E-Mail us at: KIAINSURANCE@aol.com