Watercraft Quote Form

BrokerForce Insurance Inc.
200 Consumers Rd. Suite 608
Toronto, Ontario M2J 4R4

Toll free:
800.263.9870
GTA:
416.494.2696
Fax:
416.494.7130

Name:
 Last: First:
Address:
City:
Province: Postal Code:

Phone 1:
Phone 2:
Fax:
Email:

Desired effective date:
(Month ##, ####)
Year: Maximum Speed:
Make: Vessel Value:
Model: PWC: Yes No
Length: Trailer: Yes No

Horsepower:
if YES:
Year:
Engine Type: Inboard   Make:
  Jet   Serial #
Inboard/Outboard   Value:
Outboard Any other pertinent information:
Engine Year:
Engine Make:
Engine S.N. :
Engine Value:
Coverage: Liability: 1 million OR 2 million

Driver Information
Prior Insurance Information
Name if different from above: (Last, First) Previous Insurer:
Insurance ever cancelled? Yes No
Date of Birth:
(Month ##, ####)		 Claims Info (boating losses only, past 3 years)

Boating courses:

 Yes No
Date:
Experience: None OR Years:
Type:
 
Paid: