Moller Insurance

Watercraft Insurance Quote

IMPORTANT: Please be accurate in completing this form. Your quotation will be based on the information you give us today. If these facts change, your rate will be subject to adjustment. The information transmitted is used by this brokerage to develop a prospect profile, and may or may not be used in the pricing of any estimated policy premiums.

_ Personal Information

First Name:

Last Name:

E-mail Address:

Address:

Apt. Number:

City:

Province:

Postal Code:

Home Phone:

Business Phone:

Fax Number:

Occupation:

__ Watercraft Information

Year:       Original Cost :

Horsepower:       Speed:       Length:

Type:       Waterway:       Construction:

__ Current Policy Information

Insurance Company:

Policy Number:

Policy Expiry Date:

__ Operator Information

NOTE: Drivers Licence numbers may be significant to the underwriting accuracy and will speed the return of your quotation request.

First Name:

Last Name:

Operator's Licence Number:

Relation to Applicant:

Date of Birth:

Sex: Male Female

Date First Licenced in Canada:

Do you hold a valid licence in another country? Yes No

State if driver's licence has been suspended or revoked in the past 6 years.

Please recheck to make sure you have supplied all information requested.
Please make sure each section is filled, so that all your applicable discounts can be determined.

By submitting this form you agree that the information you are providing is true and accurate

Coverages cannot be bound or changes made through our website or e-mail. You must call our office and speak to a Licenced Insurance Broker.