Parry Sound Insurance Brokers Ltd.

7 William Street, Unit #2
Parry Sound, Ontario
CANADA
P2A 1V2
Tel: (705) 746-2725
Fax: (705) 746-6420

Quotation for Watercraft

If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: psinsure@zeuter.com
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.
Information requested below 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:

City/Town:

Province:

Postal Code:

Home Telephone:

Business Telephone:

Fax Number:

Occupation:

Watercraft

Year:

Original Cost:

Length:

Speed:

Horsepower:

Current Policy Information

Insurance Company:

Policy Number:

Policy Expiry Date:

Operator Information

Driver's licence numbers may be significant to the underwriting accuracy and will speed the return of your quote.

Operator's First Name:

Last Name:

Operator's Licence Number:

Relation to Applicant:

Date of Birth:

Sex: Male Female

Date First Licenced in Canada?

Occupation:

Do you hold a current license valid in another country? YesNo

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 in filled, so that all your applicable discounts can be determined.

Parry Sound Insurance Brokers Ltd., 7 William Street, Unit #2, Parry Sound, Ontario, CANADA P2A 1V2
tel: (705) 746-2725 * fax: (705) 746-6420 * email: psinsure@zeuter.com

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Box 225, Parry Sound, Ontario, CANADA P2A 2X3 Tel/FAX (705)746-4625
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