Registered Owner: / Quote Bind
Principal Operator: / Date of Birth:
Address: / City / Province / P.C
Phone: / Member of an Association/Club (list name- discount may apply):
Loss Payable (name & full address):
List all motor vehicle moving violations in the past five years for all operators of the unit:
Have you or any other principal operator had any major moving violations in last 5 years (“major” as defined by local legislation – eg. Impaired, etc), OR has a Drivers License ever been suspended or cancelled? Yes No
Explain:
List all at fault motor vehicle accidents or claims in the past five years:
Previous Insurer: / Has Insurance ever been cancelled or refused: Yes No, Reason:
Will there be any operators that do not have a motor vehicle drivers license? Yes No Explain:
Please check one: Snowmobile ATV Off-Road Motorcycle
Year / Make / Model / CC / Serial / VIN #
Unit
Trailer
Where is your unit stored and what security measures are in place to prevent theft?
During Riding Season: / During Off-season:
Purchase Date of Unit: / Purchase Price of Unit:
List All Aftermarket Accessories / Modifications to Unit:
Total value of all accessories and modifications to Unit since new:
Policy Limit Requested
(Market Value including accessories) / Premium Quoted
(Premier usage)
Unit
Trailer ACV ($1,000 incl.)
Off-road Liability
Deductible: / ***NOTE: Premium is fully earned unless Unit is sold. Premium is earned with a seasonal factor.
NOTICE TO APPLICANT:
Keeping this coverage affordable requires making some sensible policy limitations. The policy excludes the following:Theft, when the unit, trailer or riding gear, is being stored or is not in use, unless either of the two following anti-theft precautions have been taken:
a)The unit and trailer is in a fully locked and enclosed building, and the theft leaves signs of forcible entry to the building; or
b)The unit and trailer is locked with a chain or other similar locking device which locked the unit to an immovable object. A trailer detached from the towing vehicle, or a truck deck detached from a truck, are not considered to be immovable objects.
The unit is considered to be not in use when it is stored or when it is being transported on a trailer or on a truck deck.
PLEASE READ BEFORE SIGNING APPLICATION:This application will be incorporated in its entirety into any relevant policy of insurance where Insurers have relied upon the information contained herein. Any misrepresentations or concealment in this application for insurance (including but not limited misrepresentation of moving violations or accident record), will render insurance coverage null and void from inception. Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed, if necessary by a supplement to the application. 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. Signing this form does not bind the Applicant to purchase the insurance or the Insurer to accept the risk, but it is agreed that this form shall be the basis of the contract should a policy be issued.
NOTE: INSURANCE IS NOT IN EFFECT UNTIL PREMIER HAS ISSUED A BINDER NUMBER
Signature (of applicant): / Broker Signature: / Date:
Brokerage: / Broker Email:
AGT #: / Phone: / Fax:
Premier Marine Insurance Managers Group (WEST) Inc. is one of Canada’s largest Managing Underwriting Agents. The underwriting insurance carrier varies by line of business and region - please refer to specific quote for declaration of the underwriting insurance company(s).
** Email application and attachments to - **Vancouver - T 604.669.5211 F 604.669.2667
Rev. Oct 24, 2014