Insurance Motorbike Application

Insurance Motorbike Application

Applicant / Insured Information

Applicant Name:

Date of Birth:    Phone:

Driver's License No.:    Issuing State:    Issue Date:

Motorbike Details

Make:    Model:    Year:

VIN:

Engine Capacity (cc):    Registration No.:

Use of Vehicle

Intended use (check all that apply):

  Pleasure / Social / Domestic
  Commuting to work / school
  Business use (not for hire)
  Use for hire / courier / delivery
  Racing / track days (Note: racing use is an exclusion unless specifically endorsed)

Estimated annual mileage:

Policy Request

Requested policy type:

  Liability Only
  Third-Party, Fire & Theft
  Comprehensive (recommended)

Policy period requested: From to

Premium payment frequency:   Annual   Monthly   Quarterly

Coverage Options

Select additional coverages required (if available under policy type selected):

  Collision
  Comprehensive (glass, vandalism)
  Theft / Unauthorized use
  Fire
  Roadside assistance / towing
  Medical payments / Personal injury
  Uninsured / Underinsured motorist
  Personal Accident Cover (for rider) — if selected complete beneficiary information below

Personal Accident Beneficiary

Beneficiary Name:

Relationship:    Share (%):

Driving / Claims History

Number of accidents in past 5 years:    Number of convictions / traffic offences in past 5 years:

Documentation Checklist

Please attach copies of the following with your application (tick those attached):

  Copy of Driver's License
  Vehicle Registration Certificate
  Proof of Ownership / Purchase Invoice
  Previous Insurance Policy (if any)
  Photographs of Vehicle (front, rear, odometer)

Exclusions and Important Notices

The policy does not cover loss or liability arising from: intentional acts or criminal activity by the insured; operation of the vehicle without a valid licence; use of the vehicle for racing or speed trials unless specifically endorsed; carrying passengers or goods for hire unless declared; war, nuclear hazard, and confiscation by authorities. Additional exclusions may apply as set out in the policy wording issued upon acceptance.

Material misrepresentation, omission or failure to disclose relevant facts may render the policy void from inception and may entitle the insurer to decline claims or cancel coverage. Premiums and terms are determined by underwriting and may be adjusted if undisclosed information is discovered.

Authorisations and Declarations

I hereby declare that the information provided on this application and in any documents supplied is true, complete and correct to the best of my knowledge. I acknowledge that this information will be relied upon by the insurer in determining acceptance of coverage and premium. I understand that failing to disclose material information may result in refusal of a claim or cancellation of the policy.

I authorize the insurer and its agents to obtain and exchange motor vehicle driving records, claims history, credit information where permitted by law, and other relevant records for underwriting, rating, fraud prevention and claims handling. I consent to the insurer obtaining such information from third parties and to the disclosure of my information to reinsurers or other entities for these purposes.

I agree to notify the insurer of any change in the information provided that may affect the risk, including changes in use of the vehicle, principal driver, modifications to the vehicle, or convictions. I understand that coverage takes effect only when the insurer issues a policy or provisional cover note in accordance with its underwriting rules.

  I consent to the insurer obtaining motor vehicle records and other relevant information as described above.

Additional Information / Remarks

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