Name
Address
City
Province
Postal Code
Home Phone
Bus. Phone
Cell Phone

LIST ALL LICENSED DRIVERS IN YOUR HOUSEHOLD

Driver Name	Date of Birth (MM/DD/YY)	Date Licensed	Date Class 6 Licensed	Driver License #	Driver's Training?
					Yes	No	When?	Where?

LIST ALL BIKES IN YOUR HOUSEHOLD

Year	Make	Model	CC's	Purchase Price	Purchased			V.I.N. Serial Number	Financed		Principal Driver #
					Month/Year	New	Used		Yes	No

DESCRIBE AND GIVE VALUE FOR ANY SPECIFIC EQUIPMENT AND/OR CUSTOM PAINT/FINISH

Bike #	Accessories or Modifications	Value

LIST ANY TRAILERS USED TO TRANSPORT BIKE(S)

Make	Model	Purchase Price

LIST ALL ACCIDENTS AND CLAIMS

Date	Driver #	At Fault	Not At Fault	Details

LIST ALL TICKETS AND CRIMINAL CODE CONVICTIONS IN THE PAST THREE YEARS

Date	Type	Date	Type

CURRENT INSURANCE COMPANY
Company Name:    Policy #:   
Exp. Date: 

GROUP DISCOUNTS (PHOTOCOPY OF CURRENT MEMBERSHIP CARD MUST BE PROVIDED)
AMA
CMG
Sturgess Cycle Group
Harley Owners Group
Canadian Motorcycle Guice
Canadian Motorcycle Association
Gold Wing Road Riders
Southern Cruisers

MULT-BIKE DISCOUNT:  Yes  No
(Applies when two or more motorcycles are owned by an individual or family members in the same household)

DO YOU REQUIRE A PAYMENT PLAN?:  Yes    No
(A down-payment of 25% is required with remaining payments made 30, 60, and 90 days from inception date of policy)

 

>OTHER DISCOUNTS MAY BE AVAILABLE UPON RENEWAL