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11/09/2011
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Changes to the Accident Benefits Portion of Your Auto Policy
Motorcycle Insurance
*
(denotes required field)
First Name:
*
Last Name:
*
E-Mail Address:
*
Address:
City:
Province:
Postal Code:
(X1Y 2Z3)
Phone Number:
(123-456-7890)
Age:
License #:
M1 License Date:
M2 License Date:
M License Date:
Did you take a riders training course?
Yes
No
Any tickets?
Yes
No
Any claims in last 6 years?
Yes
No
What coverage are you looking for?
All perils
Collision
Comprehensive
Specified perils
Liability Limit:
$1,000,000
$2,000,000
$5,000,000
Collision deductible amount:
$100
$250
$500
$1,000
Comprehensive deductible amount:
$100
$250
$500
$1,000
Specified perils deductible amount:
$100
$250
$500
$1,000
Year, make and model:
Value of bike:
Modified or customized?
Yes
No
Previous insurance company:
Do you belong to any Riders Associations or Clubs?
Yes
No
CAPTCHA Code:
*
