Insured's Name:
Address:
Address Line 2:
(optional)
City:
Province:
Postal Code:
Email Address:
Date of Birth:
(yyyy/mm/dd)
Years as a Boat Owner:
Number of Years Experience:
Boating Education & Courses:
Member of Cruising Club?
Yes
No
Currently Insured?
Yes
No
Renewal Date or Date Last Insured:
How Many Years Continuously Insured?
Has your insurance ever been cancelled or refused?
Yes
No
Driving Record - Have you received any tickets in the last 3 years?
Yes
No
If yes, please provide details:
Previous Insurer:
Any boating losses in the past 3 years?
Yes
No
If yes, please provide details:
Type of Vessel:
Personal Watercraft (Seadoo/Jet Ski)
Jet Drive
Small Runabout
Water-Ski Boat
Fishing Boat
Bass Boat
High Performance
Pontoon
Power Cruiser
Large Yacht
Houseboat
Riverboat
Sailboat
Other
If other, describe:
Vessel Year:
Vessel Make:
Vessel Model:
Length:
Engine Type:
Inboard
Outboard
Inboard/Outboard
# of Engines:
1
2
3
4
Total H.P.:
Fuel:
Gas
Diesel
Hull Construction:
Fibreglass
Wood
Steel
Aluminum
Max. Speed:
km/h
Market Value:
Trailer Value:
Tender Value:
Other:
(Examples: Dinghy, Equipment & Miscellaneous Items)
Liability:
$2,000,000
$1,000,000
Pleasure Use only?
Yes
No
How Many Operators: