Enter The Information Below Step 1 of 6 - General Information 16% Name First Last Email PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current Insurance Provider What Brought You To Palm Desert Insurance?Please Select OneGoogle SearchBing SearchInsurance Company ReferralReferred By FriendReferred By BusinessFacebookLinkedIn How Many Operators?*Please Make Selection1234Operator #1Driver Name Date Of Birth Month Day Year Licensed at age 16?Please Make SelectionYesNoMarital StatusPlease Make SelectionSingleMarriedGenderPlease Make SelectionMaleFemaleMinor Violations - Last 3 Years012Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.Major Violations - Last 10 Years012Major violations include DUI, Reckless Driving, Speeding Over 100, etc.Accidents - Last 5 Years0123 or MoreInclude ALL accidents regardless of fault.Operator #2Driver Name Date Of Birth Month Day Year Licensed at age 16?Please Make SelectionYesNoMarital StatusPlease Make SelectionSingleMarriedGenderPlease Make SelectionMaleFemaleMinor Violations - Last 3 Years012Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.Major Violations - Last 10 Years012Major violations include DUI, Reckless Driving, Speeding Over 100, etc.Accidents - Last 5 Years0123 or MoreInclude ALL accidents regardless of fault.Operator #3Driver Name Date Of Birth Month Day Year Licensed at age 16?Please Make SelectionYesNoMarital StatusPlease Make SelectionSingleMarriedGenderPlease Make SelectionMaleFemaleMinor Violations - Last 3 Years012Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.Major Violations - Last 10 Years012Major violations include DUI, Reckless Driving, Speeding Over 100, etc.Accidents - Last 5 Years0123 or MoreInclude ALL accidents regardless of fault.Operator #4Driver Name Date Of Birth Month Day Year Licensed at age 16?Please Make SelectionYesNoMarital StatusPlease Make SelectionSingleMarriedGenderPlease Make SelectionMaleFemaleMinor Violations - Last 3 Years012Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.Major Violations - Last 10 Years012Major violations include DUI, Reckless Driving, Speeding Over 100, etc.Accidents - Last 5 Years0123 or MoreInclude ALL accidents regardless of fault.Anyone Else In The Home Not Listed As Driver?No1234 How Many Boats/Watercraft?Please Make Selection12Watercraft #1Year, Make, Model, Length Example: 2015 Mastercraft X-23Vessel ID (If Available) This Allows Us To Provide The Most Accurate RatesMotor Serial Number (If Available) This Allows Us To Provide The Most Accurate RatesPrimary Driver Name Please assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles. Current Value What is the retail value of the watercraft as of this date?Comprehensive DeductiblePlease Select502505001000Your out of pocket expense for damage to your vehicle other than Collision Collision DeductiblePlease Select502505001000Your out of pocket expense for damage to your vehicle from a Collision Is This Watercraft Financed? No Yes Leased Trailer Coverage? No Yes Watercraft #2Year, Make, Model, Length Example: 2015 Mastercraft X-23Vessel ID (If Available) This Allows Us To Provide The Most Accurate RatesMotor Serial Number (If Available) This Allows Us To Provide The Most Accurate RatesPrimary Driver Name Please assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles. Current Value What is the retail value of the watercraft as of this date?Comprehensive DeductiblePlease Select502505001000Your out of pocket expense for damage to your watercraft other than Collision Collision DeductiblePlease Select502505001000Your out of pocket expense for damage to your watercraft from a Collision Is This Vehicle Financed? No Yes Leased Liability Limits Requested* Average - $100,000 Preferred - $300,000 Ultra Preferred - $500,000 Liability provides coverage for those you injure in an accident, outside of your vehicle. Property DamagePlease Make SelectionBasic - $50,000Average - $100,000Preferred - $250,000Ultra Preferred - $500,000Property damage covers the damage you cause to someone else's property in an accident Medical PaymentsPlease Make SelectionRejectBasic - $1,000Average - $2,500Preferred - $10,000Ultra Preferred - $25,000Med-Pay Covers out of pocket medical expenses for injuries sustained by you or other individuals in your vessel in an accident that is your fault. Optional Coverages Roadside Assistance OEM Replacement Parts Full Glass Coverage Special Equipment Can we assist you with any other policies? Auto Insurance Homeowners Insurance Umbrella Insurance Rental Properties/Landlord Insurance Motorcycle Insurance Classic/Collector/Exotic Car Insurance CCW - Firearm Liability/Self Defense Insurance Business Liability Insurance Business Property Insurance Workers Compensation Insurance Commercial Auto Insurance Bonds EIS is a full service insurance agency, with access to over 100 insurance carriers, we can match your insurance needs with the right carrier to assure you are getting the best value for your insurance premium. Secured Document Upload Drop files here or Select files Max. file size: 2 MB, Max. files: 10. If you have copies of your current insurance coverage, it is extremely helpful if you provide your current insurance docs, this allows us to provide a more comprehensive review.
