MOTORCYCLE

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Step 1 of 5

20%

Number of registered owner:
Owner #1
First name:
Last name:
Date of birth:
Str. Nbr:
App:
Street:
City:
Postal Code:
Province:
Since when have you lived at this address?
Email:
Home phone:
Work phone:
Cell phone:
Preferred contact time:
Preferred contact numbers?
Current situation?
Send me my quotes via text message (sms):
Owner #2
First name:
Last name:
Date of birth:
Street number:
appartment number:
Street:
City:
Postal code:
Province:
Since when have you lived at this address?
Email:
Home phone:
Work phone:
Cell phone:
Preferred contact time:
Preferred contact numbers?
Current situation?
Send me my quotes via text message (sms):

Informations
The reason for requesting a quote:
How did you hear about Assurance Confiance?
Home insurance renewal date (if applicable):
Current insurer:
Current annual premium:
How many years in total you ensured uninterrupted for the bike?
Duration with insurers:
Have you ever declared bankruptcy?
Are you released?
In the past 10 years, have you or anyone living with you been convicted of a criminal offence?
If so, explain why:
Do you allow access to your credit rating and accident history?

DRIVERS
Number of drivers to insure:
Driver #1
First name:
Last name:
Date of birth:
Driving licence numbers:
Gender:
Marital Status:
Levels of education attained:
Occupation:
Employment field:
Employment:
Employer:
Do you allow the insurer to go check your information with the SAAQ?
Type of licence:
Have you completed the motorcycle rider training course?
At what age did you get your motorcycle license ?
How many times your licence been suspended in the last 6 years?
If so, explain why :
Number of tickets (convictions) within the last 3 years, excluding parking tickets?
If so, detail the violations:
How many consecutive years, have you been insured as a primary driver?
How many times in the last 3 years, the insurance policy been suspended, cancelled, or refused?
If so, expand the reason:
Over the last 6 years, how many claims have been submitted to your insurer? (Also specify unreported accidents)?
Detailing the claim:
Driver #2
First name of the second driver:
Last name of second driver:
Date of birth:
Driver's license number:
Gender:
Marital status:
Levels of education attained:
Occupation:
Employment field:
Employment:
Employer:
Do you allow the insurer to go check your information with the SAAQ?
Type of licence:
Have you completed the motorcycle rider training course?
At what age did you obtain a Driver's Licence?
How many times your licence been suspended in the last 6 years?
If so, explain why:
Number of tickets (convictions) within the last 3 years, excluding parking tickets?
If so, detail the violations:
How many consecutive years, have you been insured as a driver?
How many times in the last 3 years, the insurance policy been suspended, cancelled, or refused?
If so, expand the reason:
Over the last 6 years, how many claims have been submitted to your insurer? (Also specify unreported accidents)?
Detailed the claim:
Driver #3
First name of third driver:
Last name of third driver:
Date of birth:
Driver's licence number:
Gender:
Marital status:
Levels of education attained:
Occupation:
Employment field:
Employment:
Employer:
Do you allow the insurer to go check your information with the SAAQ?
Type of licence:
Have you completed the motorcycle rider training course?
At what age did you obtain a Driver's Licence?
How many times your licence been suspended in the last 6 years?
If so, explain why:
Number of tickets (convictions) within the last 3 years, excluding parking tickets?
If so, detail the violations:
How many consecutive years, have you been insured as a driver?
How many times in the last 3 years, the insurance policy been suspended, cancelled, or refused?
If so, expand the reason:
Over the last 6 years, how many claims have been submitted to your insurer? (Also specify unreported accidents)?
Detailing the claim:

THE MOTORCYCLE
Number of motorcycles
Motorcycle #1
Motorcyle make:
Motorcycle model:
Motorcycle year:
Serial number:
Current value of the motorcycle: (excluding taxes):
Name of the Principal Driver:
Name of occasional drivers:
Name of young drivers:
Date of Purchase or lease:
Condition of the motorcycle on the possession date:
Creditor of the motorcycle?
If applicable, which is the creditor:
Does the motorcycle is leased?
If applicable, which is the lessor:
Primary use of this motorcycle:
Number of km travelled annually:
Number of km to get to work or school:
Number of Km for business year (if applicable):
Km radius of action for business (if applicable)?
Use in a competition:
Has the motorcycle been in a serious accident or rebuilt?
Is it currently insured with the new value?
Is it currently insured with the replacement value?
Is the motorcycle used outside the province?
If used outside the province, how many consecutive days maximum?
Electronic accessories (i.e. audio system or navigation system) added to the factory installed Components?
If so, what value?
Is this motorcycle currently uninsured for more than 10 days and insurers refuse to provide coverage?
Has the motorcycle been modified for performance at greater than $1000?
If so, what value?
Has the appearance of the motorcycle been modified at a cost greater than $1000?
If so, what value?
Is it used for the transport of commercial goods (i.e. Restaurant delivery, courier service, etc ...)?
Startup Blockage Mechanism:
Tracking system:
Alarme:
Engraving:
Accessories:
Description and value of the accessories:
Trailer / Sleigh (from the motorcycle):
Value:
Trailer to transport the motorcycle:
Value:
Does the motorcycle have a sidecar?
Value:
Does the motorcycle have extended forks (Chopper)?
The motorcycle #2
Motorcycle make:
Motorcycle model:
Motorcycle year:
Serial number:
Current value of the motorcycle: (excluding taxes):
Name of the Principal Driver:
Name of occasional drivers:
Name of young drivers:
Date of Purchase or lease:
Condition of motorcycles on the possession date:
Creditor of the motorcycle?
If applicable, which is the creditor:
Does the motorcycle is leased?
If applicable, which is the lessor:
Primary use of this motorcycle:
Number of km travelled annually:
Number of km to get to work or school:
Number of Km for business year (if applicable):
Km radius of action for business (if applicable)?
Use in a competition:
Has the motorcycle been in a serious accident or rebuilt?
Is it currently insured with the new value?
Is it currently insured with the replacement value?
Is the motorcycle used outside the province?
If used outside the province, how many consecutive days maximum?
Electronic accessories (i.e. audio system or navigation system) added to the factory installed Components?
If so, what value?
Is this motorcycle currently uninsured for more than 10 days and insurers refuse to provide coverage?
Has the motorcycle been modified for performance at greater than $1000?
If so, what value?
Has the appearance of the motorcycle been modified at a cost greater than $1000?
If so, what value?
Is it used for the transport of commercial goods (i.e. Restaurant delivery, courier service, etc ...)?
Startup Blockage Mechanism:
Tracking system:
Alarm:
Engraving:
Accessories:
Description and value of the accessories:
Description and value of the accessories:
Trailer / Sleigh (from the motorcycle):
Value:
Value:
Trailer to transport the motorcycle:
Value:
Value:
Does the motorcycle have a sidecar?
Value:
Value:
Does the motorcycle have extended forks (Chopper)?
The motorcyle #3
Motorcycle make:
Motorcycle model:
Motorcycle year:
Serial number:
Current value of the motorcycle: (excluding taxes):
Name of the Principal Driver:
Name of occasional drivers:
Name of young drivers:
Date of Purchase or lease:
Condition of motorcycles on the possession date:
Creditor of the motorcycle?
If applicable, which is the creditor:
Does the motorcycle is leased?
If applicable, which is the lessor:
Primary use of this motorcycle:
Number of km travelled annually:
Number of km to get to work or school:
Number of Km for business year (if applicable):
Km radius of action for business (if applicable)?
Use in a competition:
Has the motorcycle been in a serious accident or rebuilt?
Is it currently insured with the new value?
Is it currently insured with the replacement value?
Is the motorcycle used outside the province?
If used outside the province, how many consecutive days maximum?
Electronic accessories (i.e. audio system or navigation system) added to the factory installed Components?
If so, what value?
Is this motorcycle currently uninsured for more than 10 days and insurers refuse to provide coverage?
Has the motorcycle been modified for performance at greater than $1000?
If so, what value?
Has the appearance of the motorcycle been modified at a cost greater than $1000?
If so, what value?
Is it used for the transport of commercial goods (i.e. Restaurant delivery, courier service, etc ...)?
Startup Blockage Mechanism:
Tracking system:
Alarm:
Engraving:
Accessories:
Description and value of the accessories:
Trailer / Sleigh (from the motorcycle):
Value:
Trailer to transport the motorcycle:
Value:
Does the motorcycle have a sidecar?
Value:
Does the motorcycle have extended forks (Chopper)?

Guarantees
MOTORCYCLE #1
Liability:
Collision or upset deductible:
Comprehensive deductible:
#43E: Total loss - Replacement cost
MOTORCYCLE #2
Liability:
Collision or upset deductible:
Comprehensive deductible:
#43E: Total loss - Replacement cost
MOTORCYCLE #3
Liability:
Collision or upset deductible:
Comprehensive deductible:
#43E: Total loss - Replacement cost
ADDITIONAL NOTES

MOTORCYCLE

Step 1 of 5

Owner #1

Owner #2

Informations

DRIVERS

Driver #1

Driver #2

Driver #3

THE MOTORCYCLE

Motorcycle #1

The motorcycle #2

The motorcyle #3

Guarantees

MOTORCYCLE #1

MOTORCYCLE #2

MOTORCYCLE #3