Anthony Clark Insurance Brokerage

Name: *

Email Address: *

Phone Number: *

Date of Birth: *

Address: *

City: *

Province: *

Postal Code: *

Years operating a boat?: *

Boat types you have experience operating?: *

Do you have prior boat insurance history? Yes No *

Have you made in claims off your boat insurance? Yes No *

Do you have any tickets on your Alberta driver license in the past 3 years?: Yes No *

if so please give particulars:

Is this unit going to be used for business purposes?: Yes No *

What provinces will the boat be operated in?: *

Policy Effective Date: *

Liability Requested: 1,000,0000 2,000,0000 3,000,0000 4,000,0000 *

Boat Type: Sailboat Multi-Hull Sailboat Open Runabout Cabin Cruiser Ski Boat Houseboat Trawler Personal Watercraft Other *

Amount of insurance on boat: *

Boat Manufacturer: *

Year Built: *

Overall Length: *

Main Motor: none Inboard/Outboard Inboard Outboard Jetdrive Other *

Construction: Fiberglass Fiberglass Over Wood Plywood Wood Plank Aluminum Steel Concrete Other *

Year of motor: *

Type of motor: none Inboard/Outboard Inboard Outboard Jetdrive Other *

Manufacturer: *

Horsepower *

Maximum speed of motor: *

Amount of insurance on Motor: *

Twin Engine: Yes No *

Trailer: Yes No *

Year of trailer:

Make and model of trailer:

Amount of insurance on trailer:

Years operated:

Years owned:

Courses & Level Completed: *

Loss Details: *

Has any company ever cancelled or refused insurance of this description? Yes No *