| Please ensure that all details are correct and complete. Thank You |
| Name
Contact Number
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| Email Fax
Mobile
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| Address
Post Code
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| |
| DOB Of Regular Drivers
Occupation Of Insured
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| Purpose Of Use For Cycle: (Private, Business (Hire) Tour Operating)
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Use: Daily
Weekly
Weekends
Monthly
Motorcycle NCB Rating
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| NCB (Vehicle If No Cycle Rating)
Years Licenced (Cycle)
(Other)
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| Financier
Type Of Finance
|
| |
| Where is the bike left during the day and night? (Secured, Unsecured, Locked Garage, Carpark) |
| Day
Night
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| Security Fitted
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Description |
| Year Model
Make
Model
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| Registration No
Engine Number
|
| VIN Number
HOG No
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| Sum Insured
Purchase Date
Purchase Price
|
| Are you a Club member?
Yes
No
Which Club/Organisation?
|
| |
| Have you or any regular rider within the last 5 years had any of the following? |
| A policy, application or policy renewal in which you were interested declined, withdrawn or cancelled by any insurance company?
Yes
No
|
| An accident, a fire or theft, or made any claim on any insurance company with respect to a motorcycle or any other vehicle?
Yes
No
|
Any Claim Refused, or any Special Conditions or Imposed Excesses?
Yes
No |
Any Traffic Breaches/Offenses or any pending, other than parking offences?
Yes
No
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| A Criminal Conviction?
Yes
No |
| Your driving licence suspended or cancelled?
Yes
No
|
| Is the cycle in sound roadworthy condition?
Yes
No
|
Is the cycle registered in a name other than that proposed for this insurance?
Yes
No
|
If yes to any of the above, please supply full details
|
Thank you for completing our Motor Cycle Insurance Online Quotation Form.
We will assess your details and a member of our staff will be in contact with you shortly. |
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