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PERSONAL DETAILS

Name & Surname:*

Contact Number:*

E-mail:*

Address:*

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry

Age:*

Occupation:*

Licence:*

Full

Learners

Date Licence Obtained

MOTORCYCLE DETAILS

Year:*

Make:*

Model:*

Purchased through:*

Dealer

Privately

Date Purchased:*

Retail Value (Inc Extras):*

Is this the first time you are purchasing a motorcycle?:*

Yes

No

If not, what other motorcycles have you owned or ridden?:*

If you have other motorcycles, please list previous Insurers & claim history:*

MOTORCYCLE DETAILS CONTINUE

Do you currently have Motorcycle Insurance:*

Yes

No

If yes, who is your Insurer?:*

Period of Insurance:*

Any claims in the last 5 years?:

Yes

No

Are you the only named rider for this motorcycle:*

Yes

No

Will anyone under the age of 30 be riding this motorcycle?:*

Yes

No

Will you be attending any track days?:*

Yes

No

Verification:

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Please note that:

Cover will only commence after we have received:

• Thoroughly completed proposal form
• Vehicle inspection form (if applicable)
• Copy of motorcycle’s Registration Document (If applicable
• Copy of Drivers Licence / Learners Drivers Licence

Written confirmation will be faxed / emailed to the client to confirm cover.