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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:
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?
  
Any Convictions?   
Any claims in last 6 years?   
What coverage are you
looking for?
Liability Limit:
Collision deductible amount:
Comprehensive deductible amount:
Specified perils deductible amount:
Year, make and model and CC’s:
Value of bike:
Modified or customized:   
Current or previous Insurance Company Name:
Policy Number:
Policy Expiry Date:
How long have you been insured for?
Do you belong to any Riders Associations or Clubs?   
For security purposes, please write the characters in the image into the box below:
(Case Sensitive)

 

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