Nowak Insurance Agency

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Toy Insurance Quote
Are You Frustrated with Agents Misquoting Rates and then Raising the Rate at Time of Sale? *Providing the required information below will result in more accurate initial quotes.

Customer Information
First Name:*
Middle Initial:
Last Name:*
Street Address:*
Floor/Suite Number:
City:*
State:*
Zip Code:*

Email Address:*
Phone Number:*
Fax Number:

Primary Residence:*
Sex:*
Marital Status:*
Date of birth:*
Social Security Number: (Note: Required to provide an accurate price and to issue/bind a policy.)

Type of Toy to Insure: Motorcycle Boat RV

Automobile Driver License Status:*
Number of/Nature of Tickets (all Vehicles):*
Number of/Nature of AF/NAF Auto/MC Accidents:*
Number of/Nature of AF/NAF Auto/Boat/PWC Accidents:*
Number of/Nature of AF/NAF Auto/RV Accidents:*
Motorcycle/Off-Road Information
Year:*
Make:*
Model:*
CC Size:*
Is the MC a Trike?*		Yes No
Special Hazard (Turbo or Nitrous, Modified Frame)?*		Yes No
Special Construction Determination: Does the vehicle fall into any of the following categories? (If so, physical damage coverage not available.) Homemade or Composite Kit State-Assigned VIN Non-factory built MC/Trike Not listed in the NADA Appraisal Guide Original frame has been replaced

Underwriting Information
Garaging Zip Code:*
Vehicle Use:*
Names of Regular Operators:*
Names of Household Resident Operators:*

Coverage Information
Liability/Guest Passenger Limits:*
UM/UIM:*
UMPD:*
Med Pay:*
Comp/Coll Deductibles:*
Roadside Assistance:*

Custom Parts or Equipment
Paint:		$
Chrome:		$
Wheels:		$
Saddlebags/Windshield:		$
Other:		$
Total:		$
Boat Information
Type:(pleasure, fishing, sail, etc.)*
Year:*
Make:*
Model:*
Total HP (excluding trolling and kicker motors):*
Propulsion Type:*
Hull Material:*
Enhanced Performance Modifications (i.e. blowers, supercharges, etc.):
Trailer Coverage?*		Yes No
Rating Base* (include value of trailer and portable boating equipment if coverage desired):* *purchase price with taxes and title fees for TLR coverage or current market value for A/V, ACV coverage		$

Underwriting Information
Dockage/Mooring/Storage Zip Code:*
Watercraft Use (pleasure, business, etc.):*
Multi-Owner (more than one owner, not in same household):*		Yes No
Names of Regular Operators:*
Names of Household Resident Operators:*

Coverage Information
Hull Coverage:*
Hull Deductibles:*
Liability Coverage Limits:*
Uninsured/Underinsured Boater:*
Medical Payments Coverage:*
Primary Personal Effects Coverage:*
Fishing Equipment Coverage (Primary):*
Emergency Towing (on-water):*
Coastal Navigation:*
Motor Home/Travel Trailer Information
Motor Homes:*
Year:*
Make:*
Model:*
Rating Base:*
Anti-Theft Device:*		Yes No
Anti-Lock Brakes:*		Yes No
Vehicle Use:*
Primary Residence:*

Underwriting Information
Garaging Zip Code:*
Names of Co-Owners:*
Names of Regular Operators:*
Names of Household Resident Operators:*

Coverage Information
Physical Damage Coverage:*
Physical Damage Deductibles:*
Liability Coverage Limits:*
Uninsured/Underinsured:*
Medical Payments Coverage:*
Emergency Expense Coverage:*
Vacation Liability ($10,000 - $500,000):*
Personal Effects Coverage ($1,000 - $99,000):*
Deluxe Package (Disappearing Deductibles & Scheduled Medical Benefits)?*		Yes No
Roadside Assistance?*		Yes No
Full-Timers Package:
Trailer Coverage (up to $20,000; $2,500 coverage included):

Contact us:

1913 S. Illinois St.
Belleville, IL 62220

Phone:	618-236-1500
	618-281-1700
Fax:	618-236-1501
Email: info@NowakInsurance.com

Toy Insurance Quote

Customer Information

Motorcycle/Off-Road Information

Underwriting Information

Coverage Information

Boat Information

Underwriting Information

Coverage Information

Motor Home/Travel Trailer Information

Underwriting Information

Coverage Information

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