OFFSHORE INSURANCE APPLICATION

CLIENT INFORMATION
Name of Owner(s):*
Separate each Owner's name (First + Last) with a comma ( , )
Address:*
City*
Prov/State:*
Use Province/State Abbreviation (Ex. BC)
Postal/Zip Code:*
Mobile Ph:
Email:*
example@example.com
Date of Birth:*

DayMonthYear
Date
Occupation:
Nationality:
Beneficial Owner:
(If Not the Insured)
Mortgage Agreement / Loan Company:
Outstanding Loan Amount:
Dollars

ADDITIONAL EQUIPMENT
Click on the boxes that apply, and complete the information:

TenderAUX OutboardKicker
Jet Ski / Jet Boat Value:
Dollars
Trailer / Cradle Value:
Dollars
Liferaft Value:
Dollars
Additional Items:
Personal Effects Required
Dollars (Limit $2500 unless specifically declared)
Tender
Tender Make/Model:
Year
Length (ft):
Feet
Serial #:
Value:
Aux Outboard
Aux Outboard Make/Model:
Year:
HP:
Serial #:
Value:
Kicker
Kicker Make/Model:
Year:
HP:
Serial #:
Value:

EXPERIENCE INFORMATION
Experience in Owning Boats:*
# of Years
Experience in Operating Boats:*
# of Years
Previous Vessels Owned:
Separate each Vessel with a comma ( , )
Boating Courses Completed:
Separate each Course with a comma ( , )
Yacht Club Membership:

YesNo
Name of Club:
Losses Obtained During Past Five Years (please describe including date & amount):*
Have you or any other person who will be in charge of your vessel ever been charged with or convicted of any offence relating to dishonesty, theft, fraud, arson, robbery or any other criminal offence which might affect the assessment of this risk:

YesNo
If Yes, please explain:*
Current / Previous Policy Carrier:
Premium:
Is your boat for sale:*

YesNo
Has your boat policy been cancelled or non-renewed?*

YesNo
Additional Comments:

SIGNATURE AND REVIEW
How did you find us?
Eg: Website, Ad, Referral (who referred you?)
I understand that the above information is correct and complete to the best of my knowledge, is to be the bases of this insurance, if granted, but does not obligate me to accept the insurance nor for the company to accept the risk.
Signature:

Clear
Where (a) an Applicant for this contract gives false particulars to the prejudice of the insurer or knowingly misrepresents or fails to disclose any fact in any part of this application required to be stated therein; or the Insured contravenes a term of the contract or commits a fraud; or (c) the Insured willfully makes a false statement in respect of a claim, a claim will become invalid and the Insured’s right to recovery is forfeited. The Applicants have reviewed all parts and attachments of this application and acknowledge that all information is true and correct and understand that this application for insurance is based on the truth and completeness of this information. I have provided personal information in this document and otherwise and I may in the future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal information, subject to the law and to my broker’s or insurance company’s policy regarding personal information, for the purposes of communicating with me, assessing my application for insurance and underwriting my policies, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf.
Should be Empty:

CLIENT INFORMATION

VESSEL INFORMATION

ADDITIONAL EQUIPMENT

Tender

Aux Outboard

Kicker

NAVIGATIONAL INFORMATION

EXPERIENCE INFORMATION

SIGNATURE AND REVIEW