ASSOCIATED BROKER QUICK QUOTE - Motorcycle Underwriting Room

INDICATION QUOTE INFORMATION

FILL OUT THE FORM BELOW

Name *

First

Last

Contact Number *

Email *

What type of riding do you do?

Make of Bike *

Model and Year of Bike *

Value of Bike *

Do you require cover for Bike Accessories? *

If yes, specify value to specify accessory type and value

Do you require cover for Riding Gear? *

If yes, specify value to specify item of gear and value

Would you like to add any of the following optional extensions:

To qualify for a discounted premium, please answer the following - Do you currently have a training certificate? *

If Yes: Course Name and Highest Certificate Level

What is your current age?

Selected Value: 25

How many years bike riding experience do you have?

Selected Value: 25

Have you had any losses (Insured and uninsured) in the past 3 years *

If Yes: Number of incidents?

Total Value of losses?

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