Name:
	Email Address:
	Age:
	Address:
	City:
	Province:
	Postal Code:
	Phone Number:
	Policy Effective Date:
	Liability Requested:	$1 million $2 million $3 million $4 million
	Boat Type:	Sailboat Multi-Hull Sailboat Open Runabout Cabin Cruiser Ski Boat Houseboat Trawler Personal Watercraft Other
	Amount of insurance on boat:
	Boat Manufacturer:
	Year Built:
	Overall Length:
	Main Motor:	None Inboard/Outboard Inboard Outboard Jetdrive Other
	Construction:	Fiberglass Fiberglass over wood Plywood Wood Plank Aluminum Steel Concrete Other
	Year of motor:
	Type of motor:	None Inboard/Outboard Inboard Outboard Jetdrive Other
	Manufacturer:
	Horsepower:
	Maximum speed of motor:
	Amount of insurance on Motor:
	Twin Engine:	Yes     No
	Trailer:	Yes     No
	Year of trailer:
	Make and model of trailer:
	Amount of insurance on trailer:
	Years operated:
	Years owned:
	Courses & Level Completed:
	Loss Details:
	Has any company ever cancelled or refused insurance of this description?	Yes     No
		Disclaimer

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