Motorcycle Insurance Quote - JW Davis Insurance Brokers

Motorcycle Insurance Quote

February 16, 2016by JWDavis

Motorcycle Quote

Step 1 of 2

Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Telephone Number*
Email Address*
Any cancellations for non-payment in the last 3 years?
When should coverage start?*
YYYY slash MM slash DD
Driver(s) Information
Date of Birth:*
YYYY slash MM slash DD
Years holding motorcycle license in Canada:*
DATE OF LICENSE:*
M1 (MM/YYYY) M2 (MM/YYYY) M (MM/YYYY)
Sex:*
Marital status:*
Motorcycle training course in the last 3 years?*
Date of course:*
YYYY slash MM slash DD
Retired:*
Minor traffic convictions in the last 3 years:*
Major traffic convictions in the last 3 years:*
(careless or impaired driving, refusing breathalyzer, etc.)
Do you currently have motorcycle insurance?
Name of previous insurance company*
Have any of above drivers had their licenses suspended or lapsed in the past 6 years?*
Have any of the drivers above had accidents or claims in the past 10 years?*

Claims Information
Claims #1
Date #1
YYYY slash MM slash DD
Claim #2
Date #2
YYYY slash MM slash DD
Claim #3
Date #3
YYYY slash MM slash DD
Motorcycle Information
Bike #1 make:*
Bike #2 make:
Year Bike#1:*
Year Bike #2:
Model Bike #1:*
Model Bike #2:
CC Bike #1:*
CC Bike #2:
Turbo Engine Bike #1:*
Turbo Engine Bike #2:
Value Bike #1:*
Value Bike #2:
Use Bike #1:*
Use Bike #2:
KM driven one way to work Bike #1 use:*
KM driven one way to work Bike #2 use:
Kilometers driven per year Bike #1:*
Kilometers driven per year Bike #2:
When was the Bike #1 purchased?
YYYY dash MM dash DD
When was the Bike #2 purchased?
YYYY slash MM slash DD
Coverage Required
Liability Bike #1:*
Liability Bike #2:
Income Replacement Bike #1:*
Income Replacement Bike #2:
Medical Rehabilitation Bike #1:*
Medical Rehabilitation Bike #2:
Medical Rehabilitation Bike #1:*
Medical Rehabilitation Bike #2:
Caregiver Bike #1:*
Caregiver Bike #2:
Housekeeping & Home Maintenance Bike #1:*
Housekeeping & Home Maintenance Bike #2:
Dependant Care Bike #1:*
Dependant Care Bike #2:
Death / Funeral Bike #1:*
Death / Funeral Bike #2:
Indexation Bike #1:*
Indexation Bike #2:
Collision deductible Bike #1:*
Collision deductible Bike #2:
Comprehensive Coverage Deductible Bike #1:*
Comprehensive Coverage Deductible Bike #2:
Is the motorcycle Modified/Customized?
Do you belong to any Riders Associations or Clubs?
Additional Information
None
What is the name of the individual or organisation that referred J. W. Davis?

Top