Test-Forms

Pleasurecraft Form:

Service Location:

Owner(s) Full Legal Name (required)

Date of Birth YYYY-MM-DD (required)

Address/Postal Code (required)

Occupation (required)

Email (required)

Phone (required)

How did you hear about us?

Operator(s) Experience

Number of Years as Boat Owner (required)

Length & Types of Boats Owned (required)

Previous Insurer

Expiry Date YYYY-MM-DD

Has insurance ever been Declined or Cancelled?
NoYes
Provide Details

Operator(s) Information

Operator #1

Name

Birth Date YYYY-MM-DD

# of Years Operating a Boat

Length & Type of Boats Operated

Boating Courses Passed
Pleasurecraft OperatorPower SquadronMember of Cruising Club

Principal Operator?
YesNo

Operator #2

Name

Birth Date YYYY-MM-DD

# of Years Operating a Boat

Length & Type of Boats Operated

Boating Courses Passed
Pleasurecraft OperatorPower SquadronMember of Cruising Club

Principal Operator?
YesNo

Operator #3

Name

Birth Date YYYY-MM-DD

# of Years Operating a Boat

Length & Type of Boats Operated

Boating Courses Passed
Pleasurecraft OperatorPower SquadronMember of Cruising Club

Principal Operator?
YesNo

Have any Owner(s)/Operator(s) had any losses or marine related insurance claims in the past 5 years?
NoYes
Provide Details:

Vessel Information

Year (required)

Make (required)

Model (required)

Length (required)

Date Purchased YYYY-MM-DD (required)

Purchase Price (required)

Current Market Value

Vessel Hull Number

Vessel Type (required)

Hull Construction (required)

Date of most recent survey YYYY-MM-DD (please attach copy of survey)

Anti Theft Tracking System (required)
YesNo

Tender/Dingy (required)
NoYes
Provide Details

Trailer

Year

Make

Model

VIN

Value

Engines

Inboard Propeller stays in water	In-Out Propeller can raise out of the water	Outboard Entire Engine is outside of hull	Auxiliary/Kicker Smaller motor for trolling/fishing	Jet Propulsion Boat is propelled by a stream of water ejected from motor

Number of Main Engines (required)

Type of Main Engine (required)

Main Engine #1 (required)

Year

Make

Model

Max Speed

Serial Number

Fuel Type

Outboard Purchase Price

Current Market Value

Main Engine #2

Year

Make

Model

Max Speed

Serial Number

Fuel Type

Outboard Purchase Price

Current Market Value

Auxiliary

Year

Make

Model

Max Speed

Serial Number

Fuel Type

Outboard Purchase Price

Current Market Value

Additional Information

Private Pleasure use only (required)
YesNo

Live Aboard (required)
YesNo

Is it Moored (required)
NoYes
Provide Details

Name of Marina

Address

City

Postal Code

Smart Plug (required)
YesNo

Security measures when boat is on the water
Private dockMoored on BuoyBoat is never stored on water
Other security measures

Security measures when boat is off the water
Trailer Hitch LockTrailer Wheel LockLocked GarageGated PropertyBoat is never out of water
Other security measures

Primary Navigation (required)
InteriorCoastal

Please note: Coverage is not considered bound until you have received confirmation from a licensed broker.

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I understand and accept the risks of communicating by email.* Yes