2021 APPLICATION FOR MOTOR INSURANCE

PREMIUMS FOR MOTOR INSURANCE – EUROPE(MOTORCYCLES)

For RV's and Comprehensive on Passenger Cars please call 800-245-8726
Third Party Liability for Passenger Cars and Trailers is the same premium as motorcycles listed below:
This Green Card Insurance is not valid in the following countries: ALBANIA, ANDORRA, AZERBAIJAN, BOSNIEN HERZEGOWINA ,BELARUS, ISRAEL, IRAN, MOROCCO, MOLDOVA, NORTH MACEDOIA, MONTENEGRO, RUSSIA, SERBIA, TUNISA, TURKEY, UKRAINE.

You should be able to purchase coverage at the border of these countries.
A $60 Policy Fee will be added to coverage and included in your total.
Do you have a trailer? *

Yes No
Select the type of Coverage you want from the dropdown list: *

APPLICATION FOR MOTOR INSURANCE – EUROPE (MOTORCYCLES)
Applicant
Last Name *
First Name *
Address *
City, State/Province, Zip *
Country *
Phone *
E-Mail *
example@example.com
Date of Birth (Please enter in European format ex. DD/MM/YYYY)
Description of the motorcycle OR Passenger Car
Make *
Year *
Model *
Plate Number *
Country of Registration *
Vehicle ID No. *
Actual Value in € *
TRAILER
Trailer Make
Trailer Year
Trailer Type
Trailer Plate Number
What Country is your trailer registered in?
Trailer Vehicle ID No.
Trailer Actual Value €
Declared value incl. supplementary equipment (in €) if applicable. This value will be the basis for your claim.
Coverage Third Party Liability
Bodily Injury € 2.500.000 per person, in case of death or injury of 3 or more persons a total of € 7,5 mio., limited to a total of € 2,5 mio. per injured person.
Property Damage € 1.000.000 Financial Damage € 50.000
(each claim)
Period from (Day, Month, Year) *

Day Month Year
Date
to (Day, Month, Year) *

Day Month Year
Date
Any days exceeding one month you will be charged for the next month (i.e June 1 to July 4th will be 2 months).
Select Number of Months for Coverage *
Enter # months
Today's Date

Month Day Year
Date
The conditions „Allgemeine Kraftfahrt Versicherungsbedingungen“(AKB) of the AXA Versicherung AG as amended from time to time shall apply.
AXA Versicherung AG/TourInsure GmbH, Herrengraben 5, 20459 Hamburg, Tel.: +49 (0)40 / 25172150, Fax: +49 (0)40 / 25172121 E-Mail: Service@Tourinsure.de, Internet: www.TourInsure.de
APPLICATION FOR A COMPREHENSIVE AND COLLISION INSURANCE – EUROPE (MOTORCYCLES)
Last Name
First Name
Address
City, State/Province, Zip
Country
Phone
E-Mail
example@example.com
Please state required duration of coverage:
Comprehensive Motor Insurance for # months
The insurance is based on the ADS 1973 as amended 1994.
Full coverage is agreed on, excluding paint blemishes and scratches.
Written conditions have priority over printed conditions.
The laws of Germany shall apply, place of jurisdiction shall be Hamburg.
The limit of indemnification per insured motorcycle is € 20.500, maximum for accessories and improvement/ finishing is € 2.500. The deductible for each claim is € 500.
No indemnity for theft in Russia, Ukraine, Poland, Hungary, Bulgaria, Croatia, Albania, Serbia, Bosnia, Latvia, Lithuania, Moldavia, Czech Republic, Macedonia, Rumania, Turkey, Iran, Israel, Morocco, Tunisia.

Review & Confirm for Payment
Motorcycle Liability Only Number of Months Selected for Coverage
Trailer Liability Only Number of Months Selected for Coverage
Liability and Comprehensive with fire, theft, vandalism and collision for your Motorcycle Number of Months Selected for Coverage
Policy Fee *
Select Your Mailing Option - Where your Original Documents should be mailed to *
If you selected to have Originals mailed to you, do you want your documents mailed the address listed above?

Yes No
Address to Ship Original Green Card Insurance Card to:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Total
DateTime
Signature *

Clear
*** IMPORTANT NOTE: Once you enter your payment information, you will be brought back to this form and you MUST hit the SUBMIT button to complete your application.

You will then receive an email receipt that will have all of your entered information and a payment receipt attached.

Note: If you are applying for Green Card Insurance and you are over 65, you will need to email a note from your physician saying you are in good health to ride. Email to: info@motorcycleexpress.com ***

Green Card Insurance Total

USD Description

Payment Method

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

PREMIUMS FOR MOTOR INSURANCE – EUROPE(MOTORCYCLES)

APPLICATION FOR MOTOR INSURANCE – EUROPE (MOTORCYCLES)

Applicant

TRAILER

Coverage Third Party Liability

APPLICATION FOR A COMPREHENSIVE AND COLLISION INSURANCE – EUROPE (MOTORCYCLES)

Review & Confirm for Payment