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Motorcycle Insurance
First Name:
Last Name:
Address:
City:
Province:
Postal Code:
Home Phone Number:
Mobile Phone Number:
Work Phone Number:
Best Time to Contact
Email:
Are you already a client of Raymond Insurance?
Yes     No
Where did you hear about us?
Motorcycle Information:
Year:
Make:
Model:
Ccs:
Current value of motorcycle
(including chrome & accessories):
Coverage Information :

Liability Limit:

Collision:
Yes     No
Comprehensive:
Yes     No
Specified Perils:
Yes     No
Driver Information:
Date of Birth:
/ /
yyyy   mm   dd
M1 License Date
(if applicable):
/ /
yyyy   mm   dd
M2 License Date
(if applicable):
/ /
yyyy   mm   dd
M License Date:
/ /
yyyy   mm   dd
Did you take a Riders Training Course:
Yes     No
Minor traffic convictions in the last 3 yrs
Major traffic convictions in the last 3 yrs:
Have you ever had your license suspended in the past 6 years?
Yes     No
Any cancellations of insurance during the past 3 years?
Yes     No
Do you belong to any riders associations or clubs? If so which one(s)?
Is there anyone else living with you that has a motorcycle license?
Yes     No
Motorcycle Insurance Information:
Date insurance is required:
/ /
yyyy   mm   dd
Name of previous insurance company:
Insurance background:
Accident/Claims Information:
Have you had accidents or claims in the past 6 years?

If yes, please list details (date, details of accident, at fault or not at fault, any injuries?)
 
Additional comments:
   
 

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