Name:

Address:

City:

Province:

Postal Code:

Phone Number:

Your Email (required)

Age:

License #

M1 License Date:

M2 License Date:

M License Date:

Did you take a riders training course? YesNo

Any tickets? YesNo

Any claims in last 6 years? YesNo

What coverage are you looking for?    All perilsCollisionComprehensiveSpecified 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: YesNo

Previous insurance company:

Do you belong to any Riders Associations or Clubs? YesNo

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