Name: Address: Work Telephone:
Province: Ontario City: Postal Code:

Best time to be contacted: Monday Tuesday Wednesday Thursday Friday 

9am-12pm  12pm-4pm 4pm-7pm

Year purchased new:
Year manufactured:
Name of manufacturer:
Length (ft.):
Is trailer permanently located: yes no
Are you over 55:
What coverages do you require on the vacation trailer:
Have you had any previous losses or cancellations: yes no
Deductible required:
It is warranted that the trailer or camper unit will be used solely for private recreation and vacation purposes and will not be used otherwise!