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Mariner Application
Please complete all sections of the application.

Name of Applicant:
Street Address:
City or Town:
Province:
Postal Code:
Telephone ( Res. ):
Telephone ( Bus. ):
Fax:

Email:

 
Yacht:

Year:
Manufacturer:
Model:
Length:
Max. Speed:
No. Of Motors:
H.P. of Each Motor:
Type Of Boat: Cruiser: Sail:   Type Of Fuel:

Type Of Drive: Inboard/Outboard: Inboard: Sail with Outboard: Sail with Inboard:

Hull Material:
Hull Design:
Hull Number:
Serial Number:
Registration Number:
Purchase Date:
Purchase Price $:
Present Value Incl. Equipment
Improvements & Taxes $:
Purchase Date of Sails/Canvas: Set 1: Set 2: Set 3:

Is Boat: Stock: Kit:   If "Kit", who assembled it?:

Does Boat have a Gallery, Sleeping Accomodations & Head: Yes: No:


Equipment
  Stove Furnace/Heater Refrigeration
Type Of Fuel:
Pilot Light: Yes:   No: Yes:   No: Yes:   No:
If propane, where is tank?
Shut-offs at Tanks: Yes:   No: Yes:   No: Yes:   No:
Shut-offs at Stoves: Yes:   No: Yes:   No: Yes:   No:

Check If Additional Equipment on Board:
Fixed CO2 System: ( Auto: or Manual: )
Anchor: How Many:
Fire Extinguishers: How Many:
Smoke Detector Alarm:  
Gas Vapour Detector:  
Engine Exhaust Fan:  
  Make Value
Sum Log
Radio DF
Radar
CB/Radio Telephone
Depth Indicator
Compass

Other ( please describe )


Trailer

Boat Trailer:
Year:
Manufacturer:
Model:
Serial Number/Identification:
    Number Of Axles: One:   Two:


Tender

Tender/Outboard Boat:
Year:
Manufacturer:
Length:
Sail: Power: Row: Model:
Serial No./I.D.:


Outboard Motor

Outboard Motor 1:
Outboard Motor 2:
Year:
Manufacturer:
H.P.:
Model:
Seroal No./I.D.:


Liens

Name And Address of Lienholder(s):
Lienholder 1: Name:
Address:
Lienholder 2: Name:
Address:


Operators

Boat Operators - Incl. Applicant Age: Occupation: Yrs. Exp. This Type Vsl.: Total Yrs. Exp.: Drivers Licence No.:

COURSES
Are operators graduates of an approved power/sailing course?
Please describe in Remarks section below. 		Yes: No:

LOSSES
Has any operator had any losses with this or any other boat in the past 5 years?
If yes, please describe in Remarks section below. 		Yes: No:

VIOLATIONS
Have you or any operator of the said vessel:

a) had a suspension of your driver's licence, because of impairment,
dangerous driving or criminal negligence within the past 6 years? 		Yes: No:

b) been convicted of an infraction relating to the sailing of a
Marine Vessel on any of the Great Lakes or Inland waters of Ontario? 		Yes: No:

c) been convicted in a court of law for Insurance Fraud? Yes: No:


General

Name of Previous Insurer:
Policy with Previous Insurer:
Expiry Date:
Was previous policy:     Cancelled?     Lapsed?     Reduced to Renew?
Explain:
Does Applicant have other insurance with Bayside?     Yes     No
If yes, please provide the Policy Numbers:
Is boat ever used for any commercial purposes?     Yes     No

Where is boat normally berthed

- when afloat?
- when laid up?       Ashore     Afloat

What waters will be navigated?       Great Lakes     Internal Waters


Coverage

Coverage Deductible Insured Amount Premium
A.   Hull and Equipment - agreed value $
B.   Boat Trailer
C.   Personal Effects
D.   Bodily Injury/Property Damage Liablity
E.   Medical Payments as stated in policy Included
F.   Tender - Outboard Boat
      Outboard Motor (1)
      Outboard Motor (2)
G.   Accidental Death as stated in policy Included
Endorsements    
    Total Premium


Remarks


All the statements in this application are true and the owner hereby applies for a contract of insurance to be based on the truth of the said statements.
Where, (a) an Applicant for a contract gives false particulars of the described craft to be insured to the prejudice of the insurer, or knowingly misrepresents or fails to disclose in the Application any fact requred to be stated therein; or (b) the insured contravenes a term of the contract or commits a fraud; or (c) the Insured willfully makes a false statement in the respect of a claim under the contract, a claim by the insured is invalid and the right of the insured to recover indemnity is forfeited.
A consumer report containing personal, credit, factual or investigative information about the Applicant may be sought in connection with this Application for insurance or any renewal, extension or variation thereof.
The completion and signing of this Application does not bind the Applicant or the Company to effect insurance on the risk: but it is agreed that this form shall be the basis of the contract should a policy be issued. Unless otherwise stated, the Applicant is both the Registered and Actual Owner of the described Yacht.




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