Name: Tom Needham Insurance Agency
Address: 3411 West Wendover Avenue, Suite B, Greensboro, NC, 27407
Telephone: (336) 855-1223

Proposed effective date*
Date Format: MM slash DD slash YYYY
Full Name*
Telephone*
Email Address*
Address
Number of Watercrafts(if more than 1 do separate request for each BUT only fill in name and specific boat info each additional)
Are you a homeowner
Number of Drivers
Please enter year, make, model, ID#'s and current values for 1) HULL, 2) MOTOR and 3) TRAILER to be quoted.
Watercraft HULL
Year
Make
Model
Hull ID
Hull Current Value
Hull Type and/or Construction
Length
MOTOR
Year
Make
Model
Motor ID
Motor Current Value
Type
Horsepower
Top Speed
TRAILER
Year
Make
Model
Trailer ID
Trailer Current Value
OTHER DETAILS
Where is craft used
Where is craft kept or stored
Driver Information #1
Full Name of Driver
D.O.B
Date Format: MM slash DD slash YYYY
State & License #
Original date licensed
Tickets or Accidents?
If yes please give full details
Social Security #
Safety Course
If yes add details
Driver Information #2
Full Name of Driver
D.O.B
Date Format: MM slash DD slash YYYY
State & License #
Original date licensed
Tickets or Accidents?
If yes please give full details
Social Security #
Safety Course
If yes add details
Driver Information #3
Full Name of Driver
D.O.B
Date Format: MM slash DD slash YYYY
State & License #
Original date licensed
Tickets or Accidents?
If yes please give full details
Social Security #
Safety Course
If yes add details
Driver Information #4
Full Name of Driver
D.O.B
Date Format: MM slash DD slash YYYY
State & License #
Original date licensed
Tickets or Accidents?
If yes please give full details
Social Security #
Safety Course
If yes add details
Do you currently have insurance?
- Yes
- No Prior Insurance Coverage
- Interested in Combined Single Limits or Umbrella Coverage
Current Carier Name
Liability limits from Prior Policy
Liability Coverage Requested
Liability Property Damage
Uninsured or Combined Uninsured/Underinsured Motorist Bodily Injury
UM/UIM Property Damage
Medical Payments
Physical Damage Coverages
Comprehensive Coverage
Collision Coverage
Towing Coverage (if available)
Type in any misc. coverages:
Additional information, instructions, or comments.(also list any special safety equipment or anything else we should know)
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