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| Name
: |
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| First
Name : |
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| Address: |
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| City: |
|
| Postal
code: |
|
| Telephones: |
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| Email: |
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| Gender: |
|
| Status: |
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| Date
of birth: |
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| Occupation: |
|
| Employer's
name: |
|
Present
insurer:
(specify the insurance company
as well as your broker,
the policy number and its expiry date)
|
|
| Quebec
driver's license since: |
|
| Permit
suspended in the past: |
|
| Details
regarding your demerit points, if any: |
|
| Criminal
antecedants: |
|
| Number
of years you have been the owner of a boat: |
|
| Number
of years you have been operating a boat: |
|
| Details
of all boating courses taken: |
|
| Provide
all the details as above on all other pilots: |
|
Accidents
or claims in the past 5 years:
(indicate dates, circumstances
and amounts) |
|
Type
of boat:
(runabout, pontoon, jet boat,
cruiser, fishing boat, catamaran, etc.)
|
|
| Hull
construction : |
|
Model
of the propeller:
(if inboard-outboard) |
|
| Year,
make, model and serial number of the boat: |
|
Value
of the boat:
(and motor, if inboard) |
|
|
Is motor an inboard, inboard/outboard or
outboard: |
|
Type
of fuel used with this watercraft:
(gazoline, diesel, electricity,
etc.) |
|
Specify
the other type of fuel that may
be aboard the watercraft:
( propane, natural gas, kerosene,etc.)
|
|
| Aluminum
or stainless steel propeller: |
Aluminum
propeller
Stainless steel propeller |
| Anti-theft
nuts / Locking shaft: |
Anti-theft nuts
Locking shaft |
| Describe
all other anti-theft systems or devices
on the watercraft: |
|
Year,
make, model, horsepower and serial number
of the motor: |
|
Value
of motor:
(if outboard) |
|
Type,
make, model of engine shaft:
(Alpha 1,2,3, TRS, OMC, Bravo
1,2, etc.) |
|
Year,
make, model and serial number
of the trailer: |
|
| Value
of trailer: |
|
Berth
to insure:
(describe and specify an
amount, if any) |
|
| Maximum
speed of the boat: |
|
| Used
for water-skiing: |
|
| Used
for racing or competitions: |
|
| Length
and width of the watercraft: |
|
Name
and address of the lienholder, if any:
(include the postal code) |
|
| Area
of navigation and where the boat is situated
during and after season: |
|
| Is
the maritime report available: |
|
When
was the survey done:
(please send it to us by
e-mail or fax: 450-699-3139) |
|
Nautical
Clubs or associations to which you belong:
(provide membership numbers,
if applicable) |
|
| If
you are a member of a marina, give the name
and address: |
|
| Is
the boat currently for sale: |
|
| Do
you sometimes rent the boat to others: |
|
Is
it used for commercial activities: |
|
Navigation
equipment:
(compass, sonar, depth gauge, radar, VHF,
Loran C, GPS, short wave radio, Satnav,
speedometer, etc.) |
|
Other
equipment:
(refrigerator, cooking range,
bunks, toilet, propane appliances, alarm
system) |
|
| Special
considerations: |
|
| Digital
photos: |
|
|
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