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Name:
Email Address:
Address:
City:
Province:
Postal Code:
Phone Number:
Age:
M1 License Date:
/
/
yyyy
mm
dd
M2 License Date:
/
/
yyyy
mm
dd
M License Date:
/
/
yyyy
mm
dd
Did you take a Riders Training Course:
Yes
No
Any Tickets?
Yes
No
Any claims in last 6 years?
Yes
No
What Coverage are you looking for
All perils
Collision
Comprehensive
Specified perils
Liability Limit:
$200,000
$500,000
$1,000,000
$2,000,000
Collision Deductible amount:
$100
$250
$500
$1,000
Comprehensive Deductible amount:
$100
$250
$500
$1,000
Specified Perils Deductible amount:
$100
$250
$500
$,1000
Year, make and model:
Value of Bike:
Modified or Customized:
Yes
No
Previous Insurance Company:
Do you belong to any Riders Associations or Clubs?
Yes
No
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Limitation of Liability
