APPLICATION FOR A MOTORCYCLE INSURANCE

APPLICATION FOR A MOTORCYCLE INSURANCE – AFRICA

Liability Only Available in Africa
Liability Coverage Rates for Africa
A $60 Policy Fee will be added to coverage and included in your total.
Last Name
First Name
Street Address
ZIP Code and City
Country
Phone
Email
example@example.com
Date of Birth/European Style DD/MM/YYYY

DayMonthYear
Date
Make of Motorcycle
Year of Motorcycle (DD/MM/YYYY)

DayMonthYear
Date
Model
Plate Number
Country of Registration

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Vehicle ID No. (VIN Number)
Actual Value in €
Declared value incl. supplementary equipment (in €) if applicable. This value will be the basis for your claim.

Yes
Desired Coverage
Third Party Liability
Bodily Injury € 500.000 Property Damage € 500.000

Coverage 1:

• Liability insurance with a limit of € 500.000 for each claim.

• The coverage is valid in all African countries.

• However, some countries demand a local insurance coverage. The insured amount might be very low.

In this case, our coverage exceeds the local policy up to a limit of € 500.000.
List the African Countries that you will be traveling to via Motorcycle.
Policy Start Date

DayMonthYear
Date
Period End Date

DayMonthYear
Date
How many months do you want coverage for?
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Subtotal
Type a question

Clear

TOTAL

USDDescription

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

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 / 251 721 50, Fax: +49 (0)40 / 251 721 21 E-Mail: Service@Tourinsure.de, Internet: www.TourInsure.de
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APPLICATION FOR A MOTORCYCLE INSURANCE – AFRICA