Mon Assurance Nautique.com
*Applicant identification:
Last name *:
First name *:
Date of birth *(dd/mm/yyyy):
Occupation and employer *:
Address *:
City *:
Postal code *:
E-mail *:
Home phone *:
Cellphone :
Work phone *:
Fax :
Name and address of creditor *:
Is this your first marine insurance? *
If not, who was the first insurer?
Effective date of your boat policy? (yyyy-mm-dd)
*DESCRIPTION OF THE BOAT TO INSURE
Watercraft
Jet boat
 Runabout
 Cuddy Cabin
Ski boat
 Deck Boat
Pontono
Ski boat
 Cruiser
Yacht
Speed boat
Year *:
Maker *:
Model *:
Length *:
Hull *:
Houseboat
(feet)
Fiberglass
Steel
Aluminium
Ferrocement
Date of purchase *(dd/mm/yyyy):
Amount of insurance (taxes included) * :
$
Wood
Mon Assurance Nautique.com
*DESCRIPTION AND VALUES OF ENGINE(S)
Year* :
Power *:
Maker *:
H.P.
Maximum speed :
Type of motor*:
Number of engines *:
MPH
Outboard
Semi-integrated
Integrated
If "outboard" engine, price paid (taxes included) *:
Included in the amount paid for the boat :
TRAILER BOAT (IF APPLICABLE)
Trailer boat * :
Yes
No
Year *:
Maker *:
Value (taxes included) *:
$
Value is included in the amount paid for the boat
* If it's a homemade trailer, please provide a copy of the registration
Turbine(s)
$ Value
Mon Assurance Nautique.com
*INFORMATION OF THE MAIN PILOT
Same as the applicant
Name* :
Date of birth* (dd/mm/yyyy):
% of usage :
%
Pilot for how many years *?
No
More than 20 hours of navigation courses ?
Yes
Which ?
(A proof will be asked before the issuance of the policy)
Suspension of the license in the last three (3) years *?
If yes, specify:
Demerit points on driving record?
If yes, specify:
Maritime claim in the last three (3) years? *
If yes, specify:
Yes
Yes
No
No
Yes
No
INFORMATIONS OF OTHER PILOTS

% of usage :

Date of birth : dd/mm/yyyy
Name :
%
Suspension of the license in the last three (3)
years?
%
Suspension of the license in the last three (3)
years?
Yes
*BOAT CONDITION
Marine inspection available *?
Yes
Are the recommendations completed?
No
Yes
Date * (dd/mm/yyyy):
No
Have the hull(s) and/or the engine(s) been modified in any way?
specify :
Homemade boat?
Yes No
If so, a maritime expertise is required.
Is the boat on sale?
No
Date of birth : dd/mm/yyyy
Name :
% of usage :
Yes
Yes
If yes, specify since when (dd/mm/yyyy):
No
Yes No
No
Mon Assurance Nautique.com
*ADDITIONAL EQUIPMENT
Propane equipment *
Yes
No
If yes, please specify : *
Anti-theft system : *
Yes
No
If yes, please specify : *
Tracking system? *
Yes
No
Chiseling ? *
Yes
No
*USAGE AND NAVIGATION AREA
Other than for recreational uses, the boat will be used for:
Renting :
Yes
No
Races or competitions :
Yes
No
Commercial usage:
Yes
No
Specify :
During the summer, where is the boat moored? *
On the trailer
Private dock
Marina
Where?
During the winter, where is the boat stored?
Usual navigation area:
Has the applicant already been refused to renew or make a boating insurance
policy? *
Yes
If yes, please specify:
No
Mon Assurance Nautique.com
ADDITIONAL ASSETS
Additional outboard engine
Maker:
Power:
H.P.:
Power:
Lbs.:
Power:
H.P.:
Amount paid (Taxes included):
Electric engine
Maker:
Amount paid (Taxes included):
Auxiliary engine (dinghy)
Maker:
Amount paid (Taxes included):
Auxiliary (dinghy)
Maker:
Power:
Amount paid (Taxes included):
Boat lift (or elevator)
Maker:
Amount paid (Taxes included):
Comments