"*" indicates required fields Step 1 of 5 20% Your DetailsName* First Last Address* Street Address Suburb State Postal Code Contact Number*Email* Period of InsuranceStart Date* DD slash MM slash YYYY Expiry Date* DD slash MM slash YYYY Insured Name* First Last ABN (if applicable)Trading Name (if applicable) Type of Cover*SelectMarket ValueAgreed ValueUse of Boat*SelectPrivate HireCharterInsured DetailsFull Legal Name* First Last Date of Birth* DD slash MM slash YYYY Occupation Car Driver Licence Number:* Expiry Date* DD slash MM slash YYYY Boat Driver Licence Number:* Expiry Date* DD slash MM slash YYYY Is the vessel financed?*SelectYesNoName of the Lender* Have you completed a Boat Course?*SelectYesNoNumber of years of Boat Experience* In the last 5 years, has the insured:Had any insurance refused or cancelled?*SelectYesNoPlease provide*DetailsDate (DD/MM/YYYY) Add RemoveHad any boat or theft claims?*SelectYesNoPlease provide*DetailsDate (DD/MM/YYYY) Add RemoveBeen convicted of any offence?*SelectYesNoPlease provide*DetailsDate (DD/MM/YYYY) Add Remove Boat DetailsHullMake:Type:YearHIN/Registation No:Construction material:Length (meters): Add RemoveMotor/sMake:YearHP:Number of motors: Add RemoveMotor Details:Serial Number:Type: (Jet/Outboard/Inboard/Sterndrive)Fuel: (Petrol/Diesel) Add RemoveTrailer:Make:YearReg: Add RemoveIs the boat parked on the street when not in use?*SelectYesNoHas Data Dot been applied to your boat?*SelectYesNoDo you require water skiing legal liability cover?*SelectYesNoPlease select your Legal Liability Limit:* 1 million 2 million 5 million 10 million Optional BenefitsDo you require cover for a Lay Up Period?*SelectYesNoLay Up Address Street Address Suburb State Postal Code If different from the Insured's AddressTick the months the boat will be in lay up January February March April May June July August September October November December GeneralStorage Description* Storage Address* Street Address Suburb State Postal Code Boat Purchase Date* DD slash MM slash YYYY Price($) :* Date last surveyed DD slash MM slash YYYY Consent* I agreeNon Disclosure: If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning. In addition to the above, following documents can be viewed on our website: PRIVACY POLICY: https://www.imcinsurance.com.au/privacy/ FINANCIAL SERVICES GUIDE (FSG): https://www.imcinsurance.com.au/financial-services-guide/ CONTACT US: IMC Insurance Brokers Pty Ltd | ABN 79 676 680 946 | AFSL 229344 Level 1 251-253 Malvern Road, South Yarra, VIC 3141 | 1300 251 253 | insure@imcinsurance.com.au Δ
