Pleasurecraft Insurance Application

Applicant Details

Applicant #1

Name:

Phone:

Email:

Credit Consent: YesNo

Birthday:

Applicant #2

Name:

Phone:

Email:

Credit Consent: YesNo

Birthday:

Address:

Loss Payable: YesNo

Loan Institution and Address:

Watercraft Operator History

Operator #1

Name:

Birthday:

Pleasurecraft Operator Card: YesNo

Years as a watercraft operator:

Years as a watercraft owner:

Size of previous boat operated/owned:

Operator #2

Name:

Birthday:

Pleasurecraft Operator Card: YesNo

Years as a watercraft operator:

Years as a watercraft owner:

Size of previous boat operated/owned:

Claims and Insurance History

Been cancelled or refused insurance: YesNo

Any accidents or claims in the past 5 years: YesNo

If yes to above:

Claim date:

Claim amount: $

Claim description:

Previous insurance on this vessel: YesNo

If yes to above:

Carrier:

Policy #:

Expiry Date:

Any criminal code convictions or charges related to driving or boating: YesNo

If yes to above:

Offence year:

Details:

Details About The Boat

Boat Type:
—Please choose an option—PowerBoatSki Boat/Wake BoatCruiserSailboatPontoonBass BoatJet Drive BoatPersonal Watercraft/Seadoo

Vessel Type:
—Please choose an option—InboardIn/OutOutboard

Hull Type:
—Please choose an option—FiberglassWoodAluminum - RivetedAluminum WeldedPlywoodSteelOther

Select Components: Sleeping QuartersDepth FinderVapour DetectorKitchenCompassAutopilotSmart PlugRadarPropaneBuilt in CO2 SystemGalleySS RadioFire ExtinguisherLiveaboard

Security Other

Moored Location and Address:

Laid Up Location:

Principally Used:

Water Skiers Liability: YesNo

Third Party Liability: YesNo

Coverage for USA Transit: YesNo

Do you require theft coverage: YesNo

If yes, does PWC come with a factory anti-theft electronic key/touch pad
(applicable to 2015 or newer units): YesNo

Security Measures on Land:

Security Measures on Water:

Anti-Theft Device:

Surveyed (attach):YesNo

Attach Survey:

Freshwater Only: YesNo

Vessel Information

Vessel used for pleasure use only: YesNo

Max Speed: Km/h

Fuel Type:

Boat Information

Hull

Year:

Make:

Model:

Length: (ft)

Serial #:

Engine (main)

Year:

Make:

Model:

HP:

Serial #:

Engine (aux)

Year:

Make:

Model:

HP:

Serial #:

Tender

Year:

Make:

Model:

Serial #:

Trailer

Year:

Make:

Model:

Length: (ft)

Serial #:

Other

Year:

Make:

Model:

Serial #:

Insurance Limits

Hull and Machinery

Original Purchase Price: $

Current Market Value: $

Deductible: $

Hull and Machinery

Original Purchase Price: $

Current Market Value: $

Deductible: $

Outboard Engine

Original Purchase Price: $

Current Market Value: $

Deductible: $

Aux Outboard Engine

Original Purchase Price: $

Current Market Value: $

Deductible: $

Dinghy or Tender

Original Purchase Price: $

Current Market Value: $

Deductible: $

Trailer

Original Purchase Price: $

Current Market Value: $

Deductible: $

Personal Effects

Original Purchase Price: $

Current Market Value: $

Deductible: $

Fishing Equipment (ACV over $500)

Original Purchase Price: $

Current Market Value: $

Deductible: $

Liability

Limit Requested: $

Applicant #1 Signature:

Date:

Applicant #2 Signature:

Date: