J. Clifton Avery Insurance Agency
Personal Insurance Business Insurance Life & Health Insurance
 

 
   
   
 
 


Name
Email
Street Address
Street Address
City, State, Zip    
Home Phone
Work Phone
Cell Phone
Date of Birth
Driver Licence # / State  


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Driver Information
Primary Driver Name
Licence # / State  
Date of Birth
Years Boating experience
Any boater safety course?
Any motor vehicle citations within the past 5 years?
 
Driver 2 Name
Licence # / State  
Date of Birth
Years Boating experience
Any boater safety course?
Any motor vehicle citations within the past 5 years?
 
Driver 3 Name
Licence # / State  
Date of Birth
Years Boating experience
Any boater safety course?
Any motor vehicle citations within the past 5 years?


Vessel Description
Year
Make
Model
Requested Limits of liability
Length and Value  
Horsepower
Maximum speed
Type of Hull
Body Style


Power Description

Engine 1
Engine Year
Engine Make
Engine Model
Engine Value
Engine Type
 

Engine 2
Engine Year
Engine Make
Engine Model
Engine Value
Engine Type


Trailer Description
Trailer Year
Trailer Make
Trailer Model
Value


Additional Equipment Description
Item Qty Value


Please use the space below to add comments regarding any special circumstances or coverage needs


 
 
Give us a call,
We've got you covered!
(800)759-7579  

Let us do the shopping to find you the best insurance rates!

email Avery for Insurance Coverage in NH                    
Portsmouth, NH Insurance Office

7 Islington Street  |  Unit 102
Portsmouth, NH 03801

Tel 603.766.3733  | Fax 603.766.3732

Directions to Portsmouth Office

Wolfeboro, NH Insurance Office
PO Box 1510  |  21 South Main Street
Wolfeboro, NH 03894

Tel 603.569.2515  |  Fax 603.569.6538

Directions to Wolfeboro Office