Fawcett Insurance

North Vancouver Insurance - Servicing all your insurance needs

Are you covered? We make sure!

Boat Owners Insurance

Your Details

First Name

Last Name

Email Address

Home Phone

Cell Phone

Work Phone

Date of Birth

Occupation

Years as Owner

Years as Operator

Power Squadron

Yes No

Pleasurecraft Operator Card

Yes No

Other Operators

Age

Pleasurecraft Operator Card

Yes No

List all accidents or claims in the past five years:

List All Accidents or Claims in the Past 5 Years

Date / Amount / Details

Any Criminal Code charges or convictions related to driving / boating

Yes No

If Yes, When & Reason

Previous Insurer

Coverage Effective

Loss Payable

(full address)

Details of Vessel

Vessel Type

In/Outboard Outboard Inboard Sailboat Jet Drive Houseboat Pontoon Inflatable Other

Other

Hull Type

Fibreglass Wood Plywood F/G Over Wood Steel Aluminum Other

Other

DESCRIPTION

HULL

ENGINE (main)

ENGINE (aux)

TENDER

TRAILER

OTHER

YEAR

MAKE

MODEL

LENGTH / HP

SERIAL/VIN

Fuel Type

Stove Type

Fridge Type

Maximum Speed (mph)

Liveaboard Boat

Yes No

Pleasure Use Only

Yes No

Description

Surveyed

Yes No

When

Surveyor

Where Principally Used

(be specific)

Moored

Yes No

Location

Where Laid Up

(land storage)

Security Measures

(describe)

Anti Theft Device Used

Purchased in

CAN USA

Purchase Date

Coverage for Transit from US required

Yes No

From Where

HULL & MACHINERY

OUTBOARD ENGINE

AUX. ENGINE

DINGHY / TENDER

TRAILER / BOATHOUSE

PERSONAL EFFECTS

PROTECTION & INDEMNITY

ORIGINAL PURCHASE PRICE

CURRENT MARKET VALUE

$

$

$

$

$

$

$

DEDUCTIBLE / RATE

-

-

-

-

-

-

-

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 applicants agree that reports containing personal, credit, factual record, premium payment or claims history may be sought or exchanged in connection with this application for insurance or renewal, extension, variation or cancellation thereof.

PREMIUM IS FULLY EARNED – MINIMUM ANNUAL RETAINED

(Unless Watercraft is sold).

Date

Agent

Agency

Agent Phone

Agent Fax

Agent Email

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Tenant Insurance

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Boat Insurance

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PH: 604.929.3494