Fawcett Insurance North Vancouver Insurance - Servicing all your insurance needs Are you covered? We make sure! Boat Owners Insurance Name 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 Home Owners Insurance Rental Home Insurance Rental Condo Insurance Condo – Townhouse Insurance Tenant Insurance Business Insurance Motorcycle Insurance Boat Insurance TALK TO A FAWCETT INSURANCE REPRESENTATIVE NOW! PH: 604.929.3494