APPLICANT INFO / QUOTE ONLY PLEASE BIND
Name of Insured: / Lienholder:
Postal Address: / Address:
City: / P.C.: / D.O.B.: / City: / P.C.:
DESCRIPTION OF PROPERTY
Model Year: / Trade Name: / Size: / Model: / Serial No.:
Location of Unit, Name of Park, Legal Address: / P.C.:
Purchase Date: / Purchase Price: / Approx. New Cost: / Amount of Lien of Encumbrance:
Have you been employed for the last 12 months? YES NO Occupation:
Occupancy: Primary Summer/Seasonal / PREMIUM CALCULATION
Primary heat (fuel?) / Is unit fully skirted? YES NO / Base Premium
Protection: Protected Semi Unprotected / Add. for Increase in Contents / +
Wood Burning Device? YES NO If Yes, attach Wood Heat questionnaire / Add. for Increase in Outbuildings / +
Updates: / Hot Water Tank: / Roof: / Elec: / Plumb: / Heating: / Woodburnig Device Charge / +
COVERAGE & LIMITS / Credit for increased Deductible / -
Effective Date: / Total Square Footage (incl. porches): / Add. for $100 Glass Deductible / +
(see manual for minimum replacement value guide) / SUB TOTAL PREMIUM / =
Policy Form: All Risk Named Perils / Mortgage Free Discount / -
Basis of Claim Payment - Mobile Home: ACV RC / Personal Property: ACV RC / Mature Discount (at 55 yrs.) / -
Optional Deductibles: $1000 $2500 $100 Glass / Monitored Alarm: Burglar Fire / Claims Free / -
PART IPrincipal Residence / Monitored Burglar Alarm / -
A. Mobile Home / B. Outbuildings / C. Personal Property / D. Additional Living Expense / Monitored Fire Alarm / -
$ / $ / $ / $ / Factory Double Wide Discount / -
PART IIComprehensive Personal Liability (CPL) / Optional Coverage / +
E. Bodily Injury Property Damage / F. Medical Payments / G. Voluntary / Earthquake / +
$ / $ 2,500 / $ 1,000 / Liability Extensions / +
Optional Coverages required (refer to manual for rates) / SUB TOTAL PREMIUM / =
Do you require 2 million liability? YES NO / POLICY FEE: / + _$25__
Do you have any of the following liability exposures? (refer to the manual for rates) / TOTAL DUE: / =
Additional Residence Seasonal/Rented to others Incidental Office Use Incidental School (max 3) Outboard Motor & Inboard/Outboard Motors
Day Care (max. 3) Swimming Pool &/or Hot tub Saddle or Draft Animals Farmers Personal Liability 25 HP to 50 HP 51 HP to 100 HP 101 HP & up
Previous Insurer: / Expiry Date: / Previous Losses (past 5 years):
Have you ever had insurance refused or cancelled? YES NO Reason:
PLEASE READ BEFORE SIGNING APPLICATION: Any misrepresentations or concealment in this application for insurance will render insurance coverage null and void from inception. A consumer report containing personal, credit, factual or investigative information about the application may be sought in the connection with this application for insurance or any renewal, extension or variation thereof. It is understood that the personal information, furnished through this request, will be used by the Premier Marine Insurance Managers for the investigation and determination of the possible applicability of insurance, and for such other lawful purposes in accordance with any federal or provincial laws that may apply.
NOTE: INSURANCE IS NOT IN EFFECT UNTIL PREMIER MARINE HAS ISSUED A BINDER.
Signature of Applicant: / Date:
Brokerage Firm: / Signature of Broker
Broker Tel: / Broker Fax: / Broker Email:
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 / Toronto - T 416.365.0444 F 416.365.0446
Rev. Oct 27, 2015