Proposer Details
Period of insurance
From (dd/mm/yy)
to (dd/mm/yy)
Title:
First name:
Surname:
Number and Street
Town/City
County
Postcode
Telephone Number (Day):
Telephone Number (Evening):
E-mail Address
Date of Birth: (dd/mm/yy)
Age:
Gender:
Marital Status:
Precise Occupation full and part time. If unemployed
please state nature of previous employment
Employers Business:
How long resident in UK:
Type of UK Licence held:
Period held:
Any physical or mental defect, impairment of sight, hearing,
heart, diabetic or epileptic condition or other complaint
Have you or any other person who may drive this vehicle
(i) Had any motoring convictions or are there any prosecutions pending
or police enquiries outstanding (including fixed penalty offences)?
Yes give names, offences, dates, penalties and points.
(ii) had any criminal convictions (or been
charged with a criminal offence but not yet tried)?
Yes give full details.
Has any company or underwriter at any time
in respect of motor insurance declined to insure you, cancelled your
policy or refused to renew or required increased premium or special
terms?
Yes give details.
Have there been any accidents, thefts or
losses (whether covered by insurance or not and regardless of blame)
during the past 3 years in connection with any vehicle
owned or driven by you?
Yes give date(s), circumstances and costs and state whether
No Claims Bonus was affected.
Are the motorcycles kept at the above address?
No state garaging address - you must advise post code
Motorcycle Details
We can only insure motorcycles that are, or will be, registered
for road use
Please state the number of bikes owned:
Do you own a car?
Details of first bike to be insured
Make and model of motor cycle (and side car)
Details of any modification (State none if
none)
Cylinder Capacity
Estimated Value
Year of Manufacture
Date of Purchase
Price Paid
Reg. Number
Details of second bike to be insured
Make and model of motor cycle (and side car)
Details of any modification (State none if
none)
Cylinder Capacity
Estimated Value
Year of Manufacture
Date of Purchase
Price Paid
Reg. Number
Details of third bike to be insured
Make and model of motor cycle (and side car)
Details of any modification (State none if
none)
Cylinder Capacity
Estimated Value
Year of Manufacture
Date of Purchase
Price Paid
Reg. Number
Details of fourth bike to be insured
Make and model of motor cycle (and side car)
Details of any modification (State none if
none)
Cylinder Capacity
Estimated Value
Year of Manufacture
Date of Purchase
Price Paid
Reg. Number
Are all motorcycles on which insurance is
required owned by you and registered in your name?
If No give details of why you are
insuring
Insurance Cover and Use (Cover
will not be operative until a cover note has been issued)
State which cover is required
The Standard Policy provides use for social, domestic
and pleasure. Please indicate any further use required:
Please note that no cover is available for food delivery
Garaging and Security
Where is the motorcycle kept when not in
use?
Is the motorcycle fitted with an immobiliser?
If Yes , please advise make and model
of system
Is the motorcycle fitted with a tagging device?
If Yes , please advise make and model
of system
IMPORTANT NOTES - PLEASE READ This insurance will not provide cover for theft
unless a secondary security device is fitted to the motorcycle when
not in use in addition to the ignition and steering lock. Acceptable
devices include alarms, immobilisers, D Locks, brake disc locks, padlock
and chain, cable locks etc. If you are claiming a discount for the fitting
of an immobiliser or tagging device, we reserve the right to request
proof of fitting in the event of a theft claim. Please ensure that you
are able to provide evidence of fitting.If your Motorcycle is valued at over £3000. This insurance
will not provide cover for theft or malicious damage occurring at your
home (or normal address where the motorcycle is kept) between the hours
of 10pm - 6am unless the motorcycle is kept in a securely locked building.
Previous Insurance
Have you held a previous motorcycle insurance in your
own name?
If Yes please state
Name of previous insurers:
Policy Number
Expiry Date (dd/mm/yy)
How many years No Claims Bonus?
