Step 1 of 3 33% GENERAL INFORMATIONName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Day Time Phone*Email POLICY INFORMATIONCurrently Insured:* Yes No Renewal Date or Date Last Insured:* MM slash DD slash YYYY How many years continuously insured?* Was your last policy cancelled by the insurance company?* Yes No Was your last policy cancelled due to non-payment?* Yes No How many cancellations due to non-payment in the past 3 years:* VEHICLE INFORMATIONYear*Make* Model* Motorcycle Type* CC's*Vin Number* Purchase Price* Purchase Date* Month Day Year Actual Value* Is it a replica?* Yes No Handcrafted/Rebuilt?* Yes No COVERAGELiability Limit*Please Select One1,000,0002,000,000Collision Deductible*Please Select OneNone3005001,0002,500Comprehensive Deductible*Please Select OneNone1003005001,0002,500DRIVER INFORMATIONSex* Male Female Prefer Not to Answer Birth Date* Month Day Year Marital Status*Please Select OneSingleMarriedSeparatedDivorcedWidowedDrivers License No. License Expiry Date Year Month Day LICENSE DATES: All fields below are required. If not applicable, please check the N/A fieldG (yyyy/mm) G1 (yyyy/mm) G2 (yyyy/mm) M (yyyy/mm) M1 (yyyy/mm) M2 (yyyy/mm) Approved Driver's Training* Yes No Commute to Work or School* Yes No If yes, Distance One Way (in km's)Business Use* Yes No Annual Km's Driven* Any Traffic Violations in the past 3 years? Yes No If yes, provide dates and details of each conviction in the box below:Any Accidents/Claims in the past 6 years? Yes No If yes, provide dates and details of each accident claim in the box below:Any license suspensions in the past 6 years? Yes No If yes, provide details why your license was suspended, date of suspension and date of reinstatement:Any other drivers in the household:* Yes No If yes, do they have their own vehicle and insurance? Yes No CommentsThis field is for validation purposes and should be left unchanged.
