Marine Insurance Application Form

Owner`s Name: *

Address:

Telephone: *

Email:

Fax:

Occupation of Insured:

Lienholder name, address and postal code:

Vessel Year, Make & Model:

Vessel Length:

Current market (resale) value:

Serial Number:

Vessel Name:

Lisence/Registration:

Purchase Date:

Purchase Price:

Power:

Hull Style:

Sailboats:

Other Propulsion:

Construction:

Custom Vessel/Professional Builder:

Home Built:

Engine Year, Make & Model:

Engine Serial Number:

Maximum Horsepower:

Maximum Speed:

Fuel:

Stainless Steel Propeller(s):

Trailer Year, Make & Model:

Leave Blank if it does not apply.

Tender Year, Make & Model:

Leave Blank if it does not apply.

Outboard Motor Year, Make & Model:

Leave Blank if it does not apply.

Other Equipment Year, Make & Model:

Please Describe. Leave Blank if it does not apply.

Radar Year, Make & Model:

Depth Finder. Year, Make & Model:

G.P.S. Year, Make & Model:

V.H.S. Year, Make & Model:

Other Electronics Year, Make & Model:

Please Describe. Leave Blank if it does not apply.

Appliances:

Stove

Heater

Barbeque

Refrigeration

Continuous Burning Pilot light:

Where is the fuel tank located:

Fire Extinguishing System:

CO2

Halon

Area Protected:

Safety Appliances:

Fume Detector

Automatic Bilge Pump

Engine Blower

Smoke Detector

Auxiliary Generator Fuel Type:

Is the vessel equipped according to Canadian Coast Guard Standards: *

Sailboats, Describe Sail inventory:

Leave Blank if it does not apply.

Winter Lay-Up Location:

Lived Abord (winter):

Yes

Location:

Ashore

Afloat

Summer mooring location:

Water Navigated:

Is the vessel lived abord during the summer:

Water skiing/tubing/Knee boarding, towing ... etc:

Is the vessel a race boat or used for or in races:

Please Describe below. Leave Blank if it does not apply.

Is the vessel used commercially or chartered:

Please Describe below. Leave Blank if it does not apply.

Is the vessel corperately owned:

Please Describe below. Leave Blank if it does not apply.

If you charter your yacht what is the length of employment in commercial operations:

Leave Blank if it does not apply.

If you charter your yacht what are the estimated annual gross receipts:

What is the passenger capacity of the vessel:

Do you employ a paid crew or Captain:

Qualifications and experience of all operators:

Include applicant, age, years experience (owner/ operator), size of vessels (owner/ operator), drivers licence number.

Are all the operators graduates of an approved power/sailing course:

Please describe.

Has any operator or owner had any losses with this or any other boat in past 5 years:

Leave blank if it does not apply.

List all other insurance losses in excess of $5000 within the past 5 year period:

Leave blank if it does not apply.

Suspension of Licence:

Yes

Have you or the operator of the vessel had a suspension of your lisence because of an impairment, dangerous driving or criminal negligence within the past 6 years?

Convictions:

Have you or the operator of the vessel been convicted of an infraction relating to the sailing of a marine vessel?

Have you or the operator of the vessel been in a court of law for insurance fraud:

Remarks/Losses/Violations:

Explain. Leave blank if it does not apply.

Name and policy number of previous Insurer:

Insurance Policy Expiry Date:

If your previous policy was cancelled, lapsed or renewal was refused, explain below:

Amount of insurance required for the hull and equipment:

Amount of insurance required for the tender and outboard motor:

Amount of insurance required for the boat trailer:

Amount of insurance required for the personal effects:

Amount of insurance required for injury and property damage liability:

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Marine Insurance Application Form