Name:

Email Address:

Address:

City:

Province:

Postal Code:

Phone Number:

Age:

M1 License Date:

M2 License Date:

M License Date:

Did you take a riders training course:

Any tickets?

Any claims in last 6 years?

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:

$500 $750 $1,000 

Comprehensive Deductible amount:

$500 $750 $1,000 

Specified Perils Deductible amount:

$500 $750 $1,000 

Year, Make and Model:

Value of Bike:

Modified or Customized:

Previous Insurance Company:

Do you belong to any riders associations or clubs?