Name: Address: City: Province: Postal Code: Phone number: Email: Age: License #: M1 License Date: Calendar M2 License Date: Calendar M License Date: Calendar Did you take a Riders Training Course: YesNo Any Tickets: YesNo Any claims in last 6 years: YesNo What Coverage are you looking for: All perils Collision Comprehensive Specified perils Liability Limit: $100 $250 $500 $1,000 Collision Deductible amount: $100 $250 $500 $1,000 Comprehensive Deductible amount: $100 $250 $500 $1,000 Specified Perils Deductible amount: $100 $250 $500 $1,000 Year, make and model: Value of Bike: Modified or Customized: YesNo Previous Insurance Company: Do you belong to any Riders Associations or Clubs: YesNo