C L Butcher Agency
P.O. Box 5449
Knoxville, TN 37928
(865) 689-5482
Fax: (865) 689-5491

Watercraft Quote Request

* Required Fields

Effective Date:
Your Name:
Your Mailing Address:
*Email Address:
Daytime Phone:
Choose One:
Description of Property
Motor type:
Number of Engines:
Boat Type:
Other Boat Type:
Fuel:
Maximum Speed:
Hull Material:
Other Hull Material:
Insured Watercraft
Boat
Year:
Manufacturer:
Model:
Serial Number:
Length:
TotalHP:
Outboard Motor
Year:
Manufacturer:
Model:
Serial Number:
TotalHP:
Trailer
Year:
Manufacturer:
Serial Number:
Coverage Limits
Boat (Including Auxiliary Equipment, please break down o/b information):
Outboard Motor 1. (ACV Coverage):
Outboard Motor 2. (ACV Coverage):
Boat Trailer:
Personal Property ($500 Automatic):
Commercial Towing ($400 Automatic):
Boat Liability (ACV Coverage):
Medical Payments ($1000 Automatic with Liability):
Uninsured Boater:
Optional Coverages
Agreed Value Endorsement:
Actual Cash Value:
Fishing Equipment:
Fishing Equipment - Limit:
Safety Equipment: Check all that apply
GPS:
Automatic CO2 (Halon):
Ship to Shore Radio (VHF):
Depth Sounder:
Electronic Burglar Alarm:
Radar:
Plotter:
EPIRB:
Vapor Detector Alarm:
Operator Information
Date of Birth:
Years of Boating Experience:
Waters to be Navigated
Inland waters of the following states:
Coastal waters of the following states:
Is the boat chartered or used for other than private pleasure purposes?:	Yes No
Previous Loss Information
Please describe any losses or claims filed on your Boat Insurance in the last 3 years (Date / Type / Amount):
Additional Comments:
Please click the Send button only once.