your info
your name:
city:
postal code:
phone number:
email:
driver information
number of drivers:
driver #1 - age:
driver #2 - age:
driver #3 - age:
number of years licensed
driver #1 - m1: m2: m:
driver #2 - m1: m2: m:
driver #3 - m1: m2: m:
did you attain the drivers' training certificate
driver 1: yes no
driver 2: yes no
driver 3: yes no
indicate the year and make of the bike
bike #1 - year: manufacturer:
bike #2 - year: manufacturer:
bike #3 - year: manufacturer:
please indicate the model of the bike and ccs
bike #1 - model: ccs:
bike #2 - model: ccs:
bike #3 - model: ccs:
is the bike a sport or supersports model
bike 1: yes no
bike 2: yes no
bike 3: yes no
indicate the value of the bike (taxes incl.)
bike #1: $
bike #2: $
bike #3: $
accident or claims in the last 3 years
please indicate if there have been any accident or claims in the last 3 years. this pertains to at-fault or not-at-fault accidents or any type of claims.
driver # + m: d: y: : at fault: yes no - amount paid: $
motor vehicle infractions
please indicate if there have been any motor vehicle violation infractions in the last 3 years. do not put any parking tickets. if you indicate speeding then please indicate how many km over the speed limit in the km over field.
driver # + m: d: y: - violation - km over:
suspension of license
has any driver in the household had a suspension of license in the past 6 years?
insurance cancellations
has any insurance company cancelled, declined, or non-renewed any insurance policy to the application or any of the listed drivers in the past 3 years? this would include policy cancelled by the insurance company for non-payment of premium.
driver # - m: d: y: - reason
coverages for bike 1
liability: ----- $1000000 $2000000 other
collision deductable: ----- $250 $500 $1000 other
specified perils: ----- $250 $500 $1000 other
comprehensive: ----- $250 $500 $1000 other
coverages for bike 2
coverages for bike 3
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