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About You

Your Name

Your Email

Your Telephone Number

Date of Birth

Day
Month
Year

Your Insurance History

Infringements?

How many driving infringements have you had in the last 3 years?

Suspensions/Disqualifications?

Have you ever had any licence suspensions/disqualifications in the last 3 years?

Yes No

Insurance Claims?

Have you ever had any motorcycle or theft insurance claims?

Yes No

Convictions

Have you ever been convicted of any offence (other than Motorcycle/vehicle offences)??

Yes No

Cancellations?

Have you ever had any insurance refused or cancelled?

Yes No

About Your Bike

Residential Postcode?

Postcode where the vehicle is stored at night?

Where is the Vehicle Stored?

Security Devices?

Country or Metro?

Is the location of the vehicle metro or country?

Make

Model

Engine CC

Year of Vehicle

Select Cover

Registration Type?

Your Drivers License Type?

Years of License?

Whichever you have held longest, how many consecutive years since you obtained your motor vehicle probationary/provisional licence, and/or, your motorcycle learners permit?

New or Used Vehicle?
New Used

Agreed or Market Value Cover?
Market Value Agreed Value

Vehicles Value?

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