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Marine Pleasure Craft Application

Please complete and submit this application form to receive your pleasure craft insurance quote. Fill in all fields, entering N/A if not applicable.

First Name (registered owner)

Last Name

Email

Date of Birth

Occupation

Phone

Street Address

City

Region/State/Province

Postal / Zip code

Country

Other Owners or Operators (Name, DOB, Years of Experience - list separated by commas)

Leinholder (Name & Address)

Years as Owner

Years as Operator

Pleasurecraft Operator Card

Yes

No

Previously Owned Boats (Make, Size - list separated by commas)

List all boating losses in past 5 years (Claimed or Otherwise - give date, amount & description)

Any Criminal Code charges or convictions related to boating? (If Yes, Describe)

Number of Automotive Violations in Last 3 Years (List: 1. Number of Minor 2. Number of Major 3. Number of At-fault Claims)

Vessel Name

Vessel Type

In/Outboard

Outboard

Inboard

Sailboat

Jet Drive

Houseboat

Pontoon

Inflatable

Other

Hull Type

Fiberglass

Wood

Plywood

F/G Over Wood

Steel

Aluminum

Other

Purchase Price (Including Tax)

Purchase Date

Current Market Value

Hull (Year, Make, Model, Length, Serial Number - list separated by commas)

Engine [Main] (Year, Make, Model, HP, Serial Number - list separated by commas)

Engine [Auxiliary] (Year, Make, Model, HP, Serial Number - list separated by commas)

Tender (Year, Make, Model, Length, HP, Serial Number - list separated by commas)

Trailer (Year, Make, Model, Length, Serial Number - list separated by commas)

Engine [Auxiliary] Value

Tender Value

Trailer Value

Total Value

Fuel

Stove Type

Fridge Type

Max. Speed (mph)

Pleasure Use Only?

Yes

No

Liveaboard?

Yes

No

Moorage Location

Permanently Moored on a Mooring Buoy?

Yes

No

Where Principally Used (Be Specific)

Lay Up Location (Land Storage)

Security Measures (Describe)

Surveyed (Pease Attach)

Yes

No

When

Surveyor

Previous Insurer & Coverage Effective

Have you ever had any insurance refused or cancelled?

Yes

No

Liability Limit Requested

$3,000,000

$5,000,000

Requested Effective Date

Upload File

Upload PDF file (Max 15MB)

I understand that the information set forth is correct and shall be the basis upon which insurance may be granted. Completion of this application does not bind the applicant to accept the quotation, nor does it bind the insurer to accept the risk. The applicant agrees that reports containing personal, credit, factual records, premium payments, or claims history may be sought or exchanged in connection with this application for insurance or renewal, extension, variation, or cancellation thereof.

Thanks, we'll be in contact soon.

Vancouver, British Columbia

Phone: +1 604 341 8233

Email: info@trustedcoverage.ca

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