Insurance Quotation for Personal Watercraft

Manufacturer

HP/Length

Serial #

Trailer used solely for transport:

Tender used solely for transportation between the insured vessel and shore:

Outboard Motor used with tender, or as Auxillary:

At J.D. Smith Insurance, the customer is #1.....and we work for you......not the Insurance Company!.....Peace Of Mind Insurance

Due to licensing restrictions, this quotation request is only for residents of the Province of Ontario in Canada.

	J. D. Smith Insurance Ontario P.W.C. Boat Package
	$5000,000 Third Party Liability $1,000,000 TPL Available Broad Form Coverage Trailer and Road Coverage

PWC Premiums from $300

Owners Name:
Address:
		NOTE: QUOTES ARE ONLY FOR ONTARIO RESIDENTS
Occupation:
Telephone (Bus):
Telephone (Home):
Email Address :
Lienholder (Name, Address & Postal Code):

VESSEL: All applications for vessels over 15 years of age must be accompanied by a current Marine Survey

Year Mfg:
Manufacturer:
Model:
Length:
Current Market (resale) Value:
Name of Vessel:
Serial No.:
License/Registration No.:
Purchase Date:
Purchase Price:
Type of Boat:
Type of Hull:

CONSTRUCTION:

Material:
Production:
Custom paint OR Metalic Flake Finish?		Yes No
If "yes", Please Describe:

EQUIPMENT: From the following list check the appropriate equipment which is installed in the vessel, or portable in nature, but used specifically in the operation of the vessel and included in Hull Insurance.

ELECTRONICS:

Radar:			Other Electronics (describe)
Depth Finder:
V.H.F.:
G.P.S.:

APPLIANCES:

	Fuel	If Propane/Butane, Natural Gas is Used, Where is Tank Located?	Continuous Burning Pilot Light?
Stove:			Yes No
Heater:			Yes No
Refrigeration:			Yes No
Barbeque:			Yes No
Water Heater:			Yes No

SAFETY EQUIPMENT :

Built-in Fire Extinguishing System:		Areas Protected:
Gas Fume Detector:
Smoke Detector:
Engine Blower:
Automatic Bilge Pump:
Auxiliary Generator:	(Type of fuel used)

Is Boat Equipped According to Transport Canada’s Office of Boating Safety Standards?

Yes No

BERTHING & NAVIGATION:

Vessel Berth Location:
Name of Marina/Yacht Club:
Type of Berth:
Winter Berth:
Water Navigated:

BOAT USE :

Pleasure Use Only:
Water Skiing/Tubing/Knee Boarding:
Live Aboard?
Racing:		Yes No
If Racing, Describe:

COMMERCIAL USE :

Is Boat Used Commercially or Chartered?		Yes No
If Yes, Describe:
If you charter your yacht please answer the following:
How long have you been employed in commercial operations?		yr(s)
What are the estimated annual gross receipts?
What is the passenger capacity of your vessel?
Does Applicant employ a Paid Crew or Captain?		Yes No

QUALIFICATIONS & EXPERIENCE OF ALL OPERATORS:

			Years Experience		Size of Vessel
	Boat Operators - Including Applicant	Age	Owner	Operator	Owner	Operator	Drivers License No.
1.
2.
3.

COURSES: Are operators graduates of an approved power/sailing course? Yes No

Describe:

LOSSES: Has any operator or owner had any losses with this or any othe boat in the past 5 years?
Yes No
If "Yes", explain in the "Remarks" section below. List all other insurance losses in excess of $5,000 within the past 5 years.


VIOLATIONS: Have you or any operator of the said vessel: (further explain in "Remarks" section below)
had a suspension of your driver's license, because of impairment, dangerous driving or criminal negligence within the pas 6 years? Yes No been convicted of an infraction relating to the sailing of a Marine Vessel? Yes No been convicted in a court of law for Insurance Fraud? Yes No
Remarks/Losses/Violations:

Name & Policy Number of Previous Insurer:

Expiry Date:

Was Previous Policy:	Cancelled by Insuring Co.?	Renewal Refused?
	Yes No	Yes No
Details:

		Amounts of Insurance Required	Deductible
A.	Hull and Equipment
B.	Tender and Outboard Motor
C.	Boat Trailer
D.	Personal Effets
E.	Bodily Injury/Property Damage Liability

For a Quick Quote, call J. D. Smith Insurance
1-800-917-SAVE (7283) or 905-764-7868

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