Protective Service Liability Application

RENEWAL QUESTIONNAIRE – MARINA FACILITIES PACKAGE / Page 1 of 2
Name of applicant:
Policy Number:
Additional Insured(s) (If applicable):
Expiry Date:

Any change in Property Limits?

/ Yes No
If yes, please advise new limits:

Any change to Boat Dealers Insurance Limit any one vessel?

/ Yes No
If yes, please advise new limits:

Any change to Boat Dealers Insurance Limit any one location?

/ Yes No
If yes, please advise new limits:

Estimated receipts for the upcoming policy term split between operations:

Nature of Work / Revenues for the next 12 months
Moorage Receipts / $
Storage Receipts / $
Boat Sales Receipts – from Boat Stock / $
Boat Sales Receipts – Consignment/ Yacht Brokerage Sales / $
Boat Rentals / $
Fuel Receipts / $
Chandlery / Boating Supplies Receipts / $
Repair Receipts / $
Restaurant Receipts – Liquor / $
Restaurant Receipts – Food / Other / $
Hauling / Lifting (on premises) / $
Hauling / Lifting (off premises) / $
Sales to USA / $
Receipts from Rental of Rooms/ Dwellings / $
Pad a/o Campsite Rental Receipts / $
Receipts from Manufacturing or Altering Products / $
Receipts from other operations (please explain): / $
Receipts from other operations (please explain): / $

Any work done on Commercial Vessels?

/ Yes No
If yes, please advise:
- Percentage of work done on commercial boats:
- Type of work done on commercial boats:
- Type of commercial vessels worked upon:

Any changes to operations?

/ Yes No
If yes, please describe:

Any known claims and/or losses in the last 12 months?

PLEASE NOTE:
The applicant agrees to notify the company of any material changes in the answers to the questions on this questionnaire which may arise during the course of this policy issued and further understands that claims may be denied if information regarding these material changes was not provided. The purpose of this questionnaire is to assist in the underwriting process. Information contained herein is specifically relied on in determination of insurability. The undersigned, therefore, warrants that the information contained herein is true and accurate to the best of his / her knowledge, information, and belief. This questionnaire and the application shall be the basis of any insurance policy that be issued and will be part of such policy. 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 of 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.
Title of Applicant: / Signature:
Brokerage: / Signature:
Broker Contact name: / Broker email:
Broker telephone: / Broker 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 / London - T 519.850.1610 F 519.850.1614
Rev. Oct 4, 2017