APPLICATION FOR YACHT INSURANCE
OWNER TELEPHONE (H) (B)
ADDRESS CODE
EMPLOYER POSITION
BOATING EXPERIENCE YEARS PERVIOUS INSURER
NAME OF THE BOAT REG. NO.
HULL TYPE YEAR BUILT MFG. BY
CONSTRUCTION: HULL TOP SIDES
PRICE NEW, INCLUDING EQUIPEMENT: $ DATE OF PURCHASE / /
PRICE IF ACQUIRED BY OTHER THAN ORIGINAL SALE: $ DATE OF PURCHASE / /
MAX. SPEED IN MPH LENGTH OF BOAT
TYPE OF ENGINE: I/O INBOARD O/B MAKE OF ENGINE H.P.
IS BOAT EQUIPPED WITH PROPANE APPLIANCE? Y N IF YES, TANK LOC.
ELECTRIC BILGE PUMP: Y N BLOWER: Y N
LIEN: $ LIEN HOLDER:
PREVIOUS CLAIMS:
WHERE IS THE BOAT MOORED:
SERVICING MARINA:
LIMIT HULL COVERAGE: $ LIMIT DEDUCTIBLE: $
LIABILITY LIMIT: $
NAVIGATION LIMITS: MUSKOKA LAKE ONLY OTHER
ESTIMATED PREMIUM: HULL $ TAX $ TOTAL $
DATE
APPLICANT’S SIGNATURE
Purves Redmond Limited Munich Re Centre 390 Bay Street, Suite 800 Toronto, ON M5H 2Y2 Phone 416.362.4246 Toll Free 1.800.465.1137
A MEMBER OF THE WELLS FARGO GLOBAL BROKER NETWORK