(08) 6147 3200
ultra@uis.com.au
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Quote Form Boat/Marine
Contacts
Situation at Risk
Skipper Details
Insurance History
Additional Information
Contacts
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Name
Email
Phone number/mobile
Date of birth
Mailing address
Address Line 1:
Address Line 2:
Town/Suburb:
Postcode:
State:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Are additional contacts required?
Yes
No
Additional Contacts
Additional Contacts #1
Name
Email
Phone number/mobile
Birth date
+ Additional Contacts
Situation at Risk
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Watercraft type
Please select
Yacht
Catamaran
Cruiser
Runabout
Personal Water Craft
Other / Let me describe
Describe watercraft type
Watercraft make/manufacturer
Watercraft model
Watercraft construction (primary materials)
Please select
Wood
Steel
Fibreglass
Polytec
Aluminium
Carbon Fibre
Ferro Cement
Kevlar
Composite / Other / Let me describe
Describe construction
Year built
Top speed knots
Top speed km/h
Is the watercraft motorised?
Yes
No
Motor type
Please select
Inboard
Outboard
IPS
Jet
Sterndrive
Other / Let me describe
Describe motor type
Where is the watercraft stored?
Please select
Air Dock
Buoy / Swing
Cradle / Hard Stand
Stack / Dry Rack Storage
Fore and Aft Moored
Marina Berth
Pile
Pile / Jetty
Pontoon
Private Pontoon / Jetty
Other / Let me describe
Describe watercraft storage
Is the watercraft stored at the primary contact person's mailing address?
Yes
No
Watercraft storage address
(Cannot be a PO Box)
Address Line 1:
Address Line 2:
Town/Suburb:
Postcode:
State:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Mooring location name (such as the name of the marina, yacht club, etc.)
Skipper Details
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Skipper Details #1
Name
Date of birth
Gender
Please select
Male
Female
How many years has this person held their skipper's ticket / boating license for?
Has this person had any boating accidents or claims in the last 5 years?
Yes
No
+ Skipper Details
Insurance History
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Next
In the last 5 years have you
i. had insurance refused, cancelled, declined, or special terms imposed?
Yes
No
ii. been declared bankrupt, placed in liquidation, receivership, or voluntary administration?
Yes
No
iii. been convicted of or had any fines imposed for any crime involving drugs, dishonestly, arson, theft, fraud, or violence against any person or property?
Yes
No
If yes to any of the above questions, please provide details. Alternatively, call us on (08) 6147 3200.
Claims History
In the last five years has the owner or business suffered any loss or claims made against you that has not already been declared?
Yes
No
List any claims from the last 5 years
Insurer
Claim date
Type of claim
Amount paid
Finalized
Description
Please select
Malicious Damage
Water Discharge/Burst Pipe
Glass External/Internal
Impact/Vehicle
Theft/Burglary
Liability – Property
Liability – Personal Injury
Electrical/Fusion/Pumps
Other
Storm Damage – Building/Contents
Fire
Accidental Damage
Storm Other
Malicious Damage
Hail Damage
Storm Damage - Fence
$
Please select
Finalized
Not Finalized
Additional Information
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Submit
Please provide any additional information relevant to your risk, or additional covers you may require
Policy effective date
Policy expiry date
Would you like to pay monthly?
Yes
No
Who is your current insurer?
What is your current premium?
$
What is your current excess?
$
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