MARINAOPERATOR’SLEGALLIABILITYAPPLICATION

PLEASEANSWERALLQUESTIONS

IFTHEYDONOTAPPLY,INDICATE“N/A”-IFSPACEISINSUFFICIENTPLEASEUSESEPARATESHEETS

1.NameofApplicant:

2.MailingAddress:

WebsiteAddress:

3.Numberofyearsinoperationunderpresentownership:

4.Nameofoperatingmanager:

5.Numberoffull-timeemployees:

6.Numberofpart-timeemployees:

7.BUILDINGDESCRIPTIONS

Note:Thisformofpolicycoverslegalliabilityfordamagetovesselsoccurringwhileinyourcare,custodyandcontrolformooring,haulingandlaunching,repairs,fuellingandstorage.Pleaselistalllocationsatwhichsuchoperationsareperformedandcheckwhichoperationsarecarriedout.

Location / Operations
A)
B)
C)

8.ANNUALREVENUES

Operation / AnnualRevenue
MooringsandSlips / $ / #ofmoorings: / #ofslips:
Storage / $ / #ofboatsstored: / Averagevalue$
HaulingLaunching / $
RepairsMaintenance / $
Fueling / $
TOTAL / $
4405, boulevard Lapinière
Brossard, QC J4Z 3T5
Tel.: 1-855-745-1010
Fax: (450) 672-5533 / 235 Yorkland Blvd. Suite 1100
Toronto, Ontario M2J 4Y8
Tel.: 1-855-745-1010
Fax: (416) 925-7260

9.FIREPROTECTIONANDSECURITYMEASURES

Premises A / Premises B / Premises C
Certifiedcentralstationalarm? / Yes No / Yes No / Yes No
Watchmanservicewhenpremisesnotopenforbusiness? / Yes No / Yes No / Yes No
Areacompletelyfencedlighted? / Yes No / Yes No / Yes No
Othermeasures?Pleasedescribe.
Arestoragecontractsalwayssigned? / Yes No / Yes No / Yes No

PleaseindicatedistancefromLocalFireDepartment:

10.STORAGEOFBOATS

PremisesA / PremisesB / PremisesC
Whatwasthemaximumnumberofboatsstoredatanyonetime? / Ashoreinbuilding
Ashoreintheopen
Whatwasthemaximumvalueofboatsatanylocation? / Afloat / $ / $ / $
Ashore / $ / $ / $

11.LIMITSREQUIRED

a)Limitforboatsafloatorashore:$

b)ProtectionandIndemnityLimit:$

12.OWNEDBOATS

Description / Motor(s) / InsuredValue
A) / $
B) / $
C) / $

13.OTHERACTIVITIES

a)Doyouoperateasailingschool? Yes No

b)Doyourentboats? Yes No

c)Doemployeesoperatemembers’boats? Yes No

d)Doyousellboats? Yes No

14.LOSSEXPERIENCE(Duringprevious5yearsforallcoveragesbeingrequested)

Year / PremiumsPaid / LossDescription / LossesPaid / OutstandingorEstimated

15.INSURANCEDETAILS

a)Insurer:

b)PolicyNumber:

c)NumberofyearswithcurrentInsurer:

d)Haveyoueverhadinsurancecancelled? Yes No

IfYes,pleaseprovidedetails:

ThisapplicationdoesnotbindtheApplicantortheCompanytocompletethisinsurancebutitisagreedthattheinformationcontainedhereinshallbethebasisofthecontractshouldapolicybeissued.

ItismutuallyagreedbetweentheCompanyandtheApplicantthatanyinspectionofpremises,operationsoranymatterpertainingtoinsuranceaffordedbytheCompany,ismadefortheuseandbenefit oftheCompany only andisnottoberelieduponbytheApplicantinanyrespect.

THEUNDERSIGNEDHEREBYACKNOWLEDGESTHETRUTH OF THE STATEMENTSCONTAINEDHEREIN.

IAUTHORIZEYOUTOCOLLECT,USEANDDISCLOSEPERSONALINFORMATIONASPERMITTEDBYLAW,INCONNECTIONWITHYOURCOMMERCIALINSURANCE POLICYORARENEWAL,EXTENSIONOR VARIATIONTHEREOF,FORTHEPURPOSESNECESSARYTOASSESSTHERISK,INVESTIGATEANDSETTLECLAIMS,ANDDETECTANDPREVENTFRAUD,SUCHASCREDITINFORMATION,ANDCLAIMSHISTORY.

SignatureofApplicant(authorizedrepresentative) Date

SUBMITTEDBY:

EMAIL:

Forcontact informationvisit:

4405, boulevard Lapinière
Brossard, QC J4Z 3T5
Tel.: 1-855-745-1010
Fax: (450) 672-5533 / 235 Yorkland Blvd. Suite 1100
Toronto, Ontario M2J 4Y8
Tel.: 1-855-745-1010
Fax: (416) 925-7260