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Motorcycle Insurance
Name:
Address:
City:
Province:
Postal Code:
(X1Y 2Z3)
Phone Number:
(123-456-7890)
Email Address:
(xxx@yyyy.zzz)
Age:
License #
M1 License Date:
(dd/mm/yyyy)
M2 License Date:
(dd/mm/yyyy)
M License Date:
(dd/mm/yyyy)
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:
$1,000,000
$2,000,000
$5,000,000
Collision deductible amount:
$100
$250
$500
$1000
Comprehensive deductible amount:
$100
$250
$500
$1000
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
Comments:
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