613-389-9966 541 Days Road #4 Kingston Ontario, K7M 3R8 infodt@pbnet.ca

Marine Pleasurecraft Application

Step 1: Contact Info

QUOTEBIND
Requested Effective Date: (*)

Reference # (*)

REGISTERED OWNER(S): (*)

DATE(S) OF BIRTH: (*)

ADDRESS: (*)

CITY: (*)

PROV: (*)

PC: (*)

PHONE #: (*)

OCCUPATION: (*)

LEINHOLDER: (*)

ADDRESS: (*)

YEARS AS OWNER OF A BOAT:

YEARS AS OPERATOR/CREW:

MEMBER OF CRUISING CLUB:

SIZE AND TYPE OF PREVIOUS BOATS (Describe):

BOATING EDUCATION & COURSES:

BOATING LOSSES IN PAST 3 YEARS (CLAIMED OR OTHERWISE – GIVE DATE AND DESCRIPTION):

Step 2: Vehicle Info

YEAR: (*)

LENGTH: (*)

VESSEL MANUFACTURER / MODEL: (*)

Hull ID #: (*)

Hull Construction: (*)

Max Speed: (*)

TOTAL PURCHASE PRICE: (*) $

DATE PURCHASED: (*)

CURRENT MARKET VALUE (Vessel + Main Motor): (*) $

MAIN MOTOR: (*)

YEAR: (*)

MAKE: (*)

HP: (*)

SERIAL #: (*)

VALUE: Include Above (*)

AUXILIARY MOTOR: (*)

YEAR: (*)

MAKE: (*)

HP: (*)

SERIAL #: (*)

VALUE: (*)

DINGHY: (*)

YEAR: (*)

MAKE: (*)

LENGTH: (*)

SERIAL #: (*)

VALUE: (*)

DINGHY MOTOR: (*)

YEAR: (*)

MAKE: (*)

HP: (*)

SERIAL #: (*)

VALUE: (*)

TRAILER: (*)

YEAR: (*)

MAKE: (*)

SERIAL #: (*)

VALUE: (*)

LIABILITY LIMIT REQUESTED: $1,000,000$2,000,000
TOTAL VALUE: (*) $

LIST ALL AUTO MOVING TRAFFIC VIOLATIONS & AT FAULT ACCIDENTS PER OPERATOR* (*past 3 yrs, date of conviction / accident, describe)

Step 3: Marine Pleasurecraft Info

WHERE IS BOAT MOORED?

IS BOAT PERMANENTLY MOORED ON A MOORING BUOY?
YESNO
PRIVATE PLEASURE USE ONLY?
YESNO (if no, describe):

LAY UP LOCATION: (*)

NAVIGATIONAL LIMITS REQUESTED: (*)

LIVE ABOARD YESNO
HAVE YOU EVER HAD ANY INSURANCE REFUSED OR CANCELLED?
YESNO
REASON:

PLEASE READ BEFORE SIGNING APPLICATION: This application will be incorporated in its entirety into any relevant policy of insurance where
Insurers have relied upon the information contained herein. Any misrepresentations or concealment in this application for insurance (including but not limited
misrepresentation of moving violations or accident record), will render insurance coverage null and void from inception. Please therefore check to make sure
that all questions have been fully answered and that all facts material to your insurance have been disclosed, if necessary by a supplement to the
application. A consumer report containing personal, credit, factual or investigative information about the applicant may be sought in connection with
this application for insurance or any renewal, extension or variation thereof. Signing this form does not bind the Applicant to purchase the insurance
or the Insurer to accept the risk, but it is agreed that this form shall be the basis of the contract should a policy be issued.

SIGNATURE OF APPLICANT(S):

BROKERAGE NAME / BRANCH: (*)

SIGNATURE OF BROKER:

BROKER PHONE/FAX: (*)

DATE: (*)

BROKER EMAIL: (*)

NOTE: Insurance is not in effect until Premier has issued a binder number. The company in its sole judgment may elect to accept or reject any application.

Premier Marine Insurance Managers Group (WEST) Inc. is one of Canada’s largest Managing Underwriting Agents. The underwriting insurance carrier varies by
line of business and region - please refer to specific quote for declaration of the underwriting insurance company(s).

** Email application and attachments to - newbizmarine@premiergroup.ca **

Western Region - T 604.669.5211 F 604.669.2667 Ontario & Atlantic Canada - T 519.850.1610 F 519.850.1614