Step 1 of 3 33% GENERAL INFORMATIONInsured's Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Address* Street Address Address Line• The type of policy issued by a company, e.g., fire line, automobile line, casualty line. • A given set of exposures making up an account. An... More 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Daytime Phone*Email Date of Birth* Month Day Year Years as a Boat Owner*Number of Years Experience*Boating Education and Courses*Member of Cruising Club* Yes No Currently InsuredThe entity (individual or otherwise) whose risk of financial loss from an insured peril is protected by the insurance policy. More?* Yes No RenewalA certificate which attests to the fact that an insurance policy has been extended for another term. More Date or Date Last Renewed* MM slash DD slash YYYY How Many Years Continuously InsuredThe entity (individual or otherwise) whose risk of financial loss from an insured peril is protected by the insurance policy. More*Has your insurance ever been cancelled or refused?* Yes No Was your last policyLegally binding contract effecting insurance or certificates thereof, including all clauses, riders, endorsements and renewals. More cancelled due to non-payment?* Yes No Driving Record - Have you received any tickets in the last 3 years?* Yes No If yes, please provide details:Previous InsurerThe company providing the insurance coverage. More:* Any boating losses in the last 3 years?* Yes No If yes, please provide details: Watercraft/Engine InformationType of Vessel*Please Select OnePersonal Watercraft (Seadoo/Jet Ski)Jet DriveSmall RunaboutWater Ski BoatFishing BoatBass BoatHigh PerformancePontoonPower CruiserLarge YachtHouseboatRiverboatSailboatOtherIf other, please describe: Vessel Year*Vessel Make* Vessel Model* Length*ENGINE INFORMATIONEngine Type*Please Select OneInboardOutboardInboard/OutboardNumber of Engines* 1 2 3 4 Total H.P.*Fuel* Gas Diesel Hull Construction* Fibreglass Wood Steel Aluminum Max Speed (km/h)* POLICY INFORMATIONMarket Value* Trailer Value* Tender Value* Other (Examples: Dighy, EquipmentMaterial for use on one machine, one vehicle, one unit. For example, a car comes “equipped” with five tires. Tires other than those on the car are... More & Miscellaneous Items)* Liability* $2,000,000 $1,000,000 Pleasure Use Only* Yes No How Many Operators*EmailThis field is for validation purposes and should be left unchanged.
