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* Mandatory Fields

Applicant's Personal Information
Registered Owners First name*
Registered Owners Last Name*
Street Address*
Town*
Postal Code*
Date of Birth* (mm-dd-yyyy)
Home Number	() -
Business Number	() -
Cell Number	() -
Email Address*

Watercraft Information
Type*	PWC Jet Boat Aluminium Boat Pontoon Boat Deck Boat In-Board Runabout Out-Board Runabout In-Board Bowrider Out-Board Bowrider Ski-Boat Wakeboard Boat Sailboat under 25ft Sailboat over 25ft Cruiser under 25ft Cruiser over 25ft Cuddy Cabin Bass Boat Speed Boat over 60mph
Year (yyyy) *
Make*
Model*
Length (in feet)*	ft.
Boat Value (Boat & Motor) Including Taxes	$
Hull Construction	Fiberglass Aluminium Wood Steel Cement
Watercraft Top Speed (miles per hour)	(mph)

Engine
Number of Engines	1 2 3
Type of Engine	In-Board Out-Board In-Board/Out-Board
Year (yyyy)
Make
Model
Horsepower	(hp)
If Out-Board Engine (Value of Engine)	$

Additional Watercraft Equipment
Electric Trolling Motor (Value)	$
Auxiliary Engine (Value)	$
Trailer (Value)	$
Dinghy (Value)	$
Dinghy Engine (Value)	$
Fishing Equipment (Value)	$
Portable Equipment (Value)	$

Watercraft Operators
Operator #1
	Fist name
	Last name
	Date of Birth (mm-dd-yyyy)
Operator #2
	Fist name
	Last name
	Date of Birth (mm-dd-yyyy)
Operator #3
	Fist name
	Last name
	Date of Birth (mm-dd-yyyy)
Operator #4
	Fist name
	Last name
	Date of Birth (mm-dd-yyyy)
Operator #5
	Fist name
	Last name
	Date of Birth (mm-dd-yyyy)
Accredited Marine Training Course
	Yes No
	Description

Claims Information
Claim #1
	Date (mm-dd-yyyy)
	Description of the loss
	Amount of the claim payout	$
Claim #2
	Date (mm-dd-yyyy)
	Description of the loss
	Amount of the claim payout	$
Claim #3
	Date (mm-dd-yyyy)
	Description of the loss
	Amount of the claim payout	$

Additional Information
Marine Survey Available	Yes No
Major Modifications On Watercraft	Yes No
Watercraft used for commercial Activities	Yes No
Watercraft used for racing	Yes No
Watercraft used in sailing competitions	Yes No
Watercraft used in poker runs	Yes No
Watercraft used for water skiing, Inflatable	Yes No
Watercraft used for wakeboarding	Yes No
Additional Comments
Send My Quote By	Phone Fax Email
How did you hear about us	Magazine Advertising Boat Show Marina/Dealer Newsletter Website Radio TV Existing Customer Referral Other