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MARINE QUOTE

 

Contact Information

 Name:
 Street Address:
 City:
 Postal Code:
 Contact Name:
 Phone Number:
 Fax Number:
 E-mail:

Other Information

 Occupation:
 Lienholder - Name:

Address:

The 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

Vessel Type

 Power Boats    
Crusier Runabout Bass Boat
Trawler House Boat High Performance
Cuddy Cabin Deck Boat

(over 50 m.p.h.)
 Hull Style    
Displacement Hull Tunnel/Catamaran
Shallow <V>   Pontoon
Deep <V>    
 Sail Boats    
Mono-Hull    
Multi-Hull    

Method of Propulsion

Outboard Inboard/Outboard Inboard Jet

Other:

 

Construction

Fiberglass Stock/Production Vessel
Aluminum Custom Vessel/Professional Builder
Wood Home Built
Steel  
Kevlar/Epoxy/Exotic Laminate
   
Custom paint or metallic flake finish?  (if yes, describe below):

 

Engine

 Engine  Make
 Serial Number  
 Year  Total Horsepower
 Maximum Speed  Fuel (Gas or Diesel)
 Is vessel equipped with stainless steel propellers?  Yes  No

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.

TRAILER used solely for transportation of the insured yacht.
  Manufacturer HP/Length Year Serial No. Value
 
TENDER used solely for transportation between the insured vessel and shore.
  Manufacturer HP/Length Year Serial No. Value
 
OUTBOARD MOTOR used with tender, or as Auxiliary
  Manufacturer HP/Length Year Serial No. Value
 

Electronics

Radar Other Electronics
Depth Finder

Details:
 
V.H.F.
G.P.S.

Appliances

  Fuel Location of Tank
(if Propane or Natural Gas)		 Continuous Burning
Pilot Light?
Stove Yes   No
Heater Yes   No
Refrigeration Yes   No
Barbeque Yes   No

Fire Protection

Built-in Fire Extinguishing System CO2 Automatic
    Halon Manual
Fume Detector Engine Blower  
Smoke Detector Automatic Bilge Pump

Areas Protected:
 
Auxiliary Generator (Type of fuel used):

 Is boat equipped according to Canadian Coast Guard standards?

Yes  No

Sailboats

 Describe sail inventory (with year of manufacture):
 

Berthing & Navigation

 Winter lay-up location:
Afloat Ashore Lived Aboard
 Summer mooring location:
 Water navigated:

Boat Use

 Pleasure Use Only? Yes  No  Live Aboard? Yes  No
 Racing? Yes  No    

Describe:
 Water Skiing/Tubing/Knee Boarding? Yes  No  

Commercial Use

 Is boat used commercially or charted? Yes  No  
 Is boat corporately owned? Yes  No  

Describe:
(either of above)
 If you charter your yacht, please answer the following:  
 How long have you been employed in commercial operations?
 What are the estimated annual gross receipts?
 What is the passenger capacity of your vessel?
 Does the Applicant employ a paid crew or captain?

Yes  No

Qualifications and Experience of all Operators

 Boat Operators - Including Applicant Years Experience Size of Vessels
  Age Owner Operator Owner Operator
 1.
 

 Drivers License No.:

    
 2.
 

Drivers License No.:

    
 3.
 

Drivers License No.:

    
 Courses: Are operators graduates of an approved power/sailing course?

YesNo
 Describe:  
 Losses: Has any operator had any losses with this or any other boat in past 5 years?

YesNo

If yes, explain:
 
 
 List all insurance losses in excess of $5000 in past 5 year period;  
   
 Violations: Have you or any operator of said vessel:  
 a) had a suspension of your driver's license, because of impairment, dangerous  

 driving or criminal charges within the past 6 years?

YesNo
 b) been convicted of an infraction relating to the sailing of a marine vessel?

YesNo
 c) been convicted in a court of law for insurance fraud?

YesNo
 Remarks/Losses/Violations:  
 

Insurance Information

 Name & Policy No. of Previous Insurer Expiry Date
 
 Was previous policy;    
Cancelled?    
Lapsed?    
Renewal Refused?    
 Explain:  
 
   

Amount of Insurance Required

Deductible

Premium
 A. Hull & Equipment

 B. Tender & Outboard Motor

 C. Boat Trailer

 D. Personal Effects

 E. Bodily Injury/Property
 Damage Liability

How should we contact you?

E-mail    Phone   Fax  Mail 

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Gray Insurance Brokers Inc.
All Rights Reserved

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