Adviser Name (if known)

First Name

Last Name

What would you like us to do? (our Scope of Service) *

Add a boat to my existing policy

Replace existing boat on my policy

Create a new boat policy

Are you:

Selling the old boat on the same date as purchasing the new boat (or trading in) so we can remove the insurance for your old boat

Still waiting for your old boat to sell, so we won't cancel this until you can confirm it has sold

Name of person completing the form

First Name

Last Name

Are you the registered owner of the boat?

YES

NO

Is the policy to be issued in the name of the registered owner?

YES

NO

Postal Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

What date do you want cover effective from?

MM

DD

YYYY

What type of boat is this?

Yacht/Sailboat

Powerboat

Launch

Jetboat

Jetski

Other

Will there be any commercial use of the boat?

YES

NO

Will the boat be raced?

YES

NO

Is the boat:

Moored

Trailered

Other

Type of mooring:

Marina

Pile

Swing

Other

Does the mooring meet the minimum port or local authority requirements for the size of the boat?

YES

NO

Does the mooring meet the minimum port or local authority requirements for its conditions?

YES

NO

Where is the boat generally kept?

Street

Driveway

Locked garage

Front yard

Back yard

Other

What security does the boat/trailer have?

Tow back lock

Wheel clamps

Coupling lock

Cable lock

Hitch helmet

Other

What do you require cover for?

Boat (hull, fixtures and fittings)

Boat trailer

Main motor(s)

Auxiliary motor

Dinghy

Fishing and sporting equipment

Sails, masts, spars, rigging

Other

What material is the boat made out of?

Aluminium

Carbon Fibre

Fibreglass

Inflatable/Rubber

Plastic

Steel

Timber or Ply

Other

Do the above figures include or exclude GST?

incl. GST

excl. GST

Not sure

Under finance or lease?

YES

NO

Is the boat sound and seaworthy?

YES

NO

Do you belong to a boat club?

YES

NO

Are any fire extinguishers kept on board?

YES

NO

By ticking this box, I confirm I have read and understood the following declaration and privacy statements

By ticking this box, I confirm I have read and understood the following authorisation statements

By ticking this box and completing and submitting this proposal form, I/we declare that to the best of my/our knowledge and belief these particulars are true, complete and correct. Subject to any right I/we have under the Clean Slate Act, I/we have not withheld any information or any other material fact likely to affect the provision of cover.

Is there anything else you would like assistance with? (we will contact you)

KiwiSaver

Homeloans

Life/Health Insurance

Domestic Insurances - e.g. house, contents, vehicle, trailer, camper van

Business Insurance

Other