Motorcycle Insurance

Name:

Address:

City:

Province:

Postal Code:

Phone Number:

Email Address:

Have you ever been cancelled or refused insurance?

Yes

Have you had insurance on a motorcycle in the past three years?

Yes

When should coverage start?

Rider Date of Birth:

	/		/
yyyy		mm		dd

M1 License Date:

	/		/
yyyy		mm		dd

M2 License Date:

	/		/
yyyy		mm		dd

M License Date:

	/		/
yyyy		mm		dd

Rider Training Course Completed?

Yes

License lapse or suspension in past three years?

Yes

Minor traffic convictions in the last 3 yrs:

Major traffic convictions in the last 3 yrs (careless or impaired driving, refusing breathalyzer, etc.)

Have you had any accidents or claims in the last 6 years?

Yes

Claims Information:

Claims

Date (mm/yyyy)

#1:

#2:

#3:

Motorcycle make:

Year:

Model:

Engine size:

Current Actual Cash Value:

Coverage Required:

Liability limit requested:

Optional Physical Damage:

Use: