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Motorcycle Insurance
* Marks a mandatory field.
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
