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Name of Owner(s)*

First Last

Address*

Street Address City Province Postal Code

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Date of birth

Date of birth*

Email*

Contact number*

Are you a current or past Skippers' Plan customer*

Yacht club or Marina name

Manufacturer and model*

Year built*

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Date of last survey

Length*

Hull material*

Number of engines*

Engine make and horsepower

Engine type*

Engine fuel

Maximum speed (power boat only)

Amount of coverage requested*

Value of boat, motor, equipment and trailer in CAN$ including taxes.

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