John B. Andrews, Inc.
30376 Esperanza, Suite 300
Rancho Santa Margarita, Ca. 92688
Office: (949) 589-1114
E-mail: john@rsminsurance.com
   
 



 
















Contact Information
  Your Full Name:
  Address:
  City:
  State:
  Zip:
  Home Phone:
  Work Phone:     Ext.
  Fax Phone:    
  Email:   

Boat Information
  Year:
  Make:
  Actual Cash Value:
  Type
  Power:
  Horsepower:
  Actual Cash Value of Engine if Outboard:
  Length (Ft.):
  Date Purchased:

Trailer Information
  Year:
  Make:
  Actual Cash Value:

Operator 1
  Name: FemaleMale
  Marital Status:   
  Date of Birth: -- (mm/dd/yyyy)
  Tickets( Last 3 Years): //1st. // 2nd. // 3rd.
  Accidents (list all accident "Dates" in the (Last 5 years):: //1st. // 2nd. // 3rd.

Operator 2
  Name: FemaleMale
  Marital Status:   
  Date of Birth: -- (mm/dd/yyyy)
  Tickets( Last 3 Years): //1st. // 2nd. // 3rd.
  Accidents (list all accident "Dates" in the (Last 5 years):: //1st. // 2nd. // 3rd.

Prior Insurance
  Company Name:
  Policy Number:
  Expiration Date: //  (mm/dd/yyyy)
  How Long?:

Coverage
  Bodily Injury::
  Medical payments:
  Deductible

Additional Comments