* Denotes required field

Insured*

Age*

Address*

City*

Telephone Number*

Email*

Postal Code*




Years as owner of a boat*

Date Purchased* mm/dd/yyyy

Vessel Year*

Make*

Model*

Engine*
O/BI/OI/B

Length*

H.P.*

Max Speed*

Market Value*

Trailer Value*

Other

Liability*
$2 Million$1 MillionPWC $1,000,000PWC $500,000PWC $250,000

Experience*
None

Boating Courses (last 3 years)*
NoneYes

Insurance ever cancelled*
NoYes

Driving Record*
ClearOther

Previous Insurer*

Boating Losses (last 3 years)*
NoneYes

Describe

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Note: Quotation only. Subject to a fully completed application. Risk not bound until Premier issues a binder.