Motorcycle Insurance Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
Date
Policy Due Date
-
Day
-
Month
Year
Date
Current Insurer
Who referred client?
Sales Team
Insured Details
Insured Name
Date of Birth
-
Day
-
Month
Year
Date
Type of Finance
Please Select
Personal Loan
Lease
Credit Union
Other
Client Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Motorcycle Details
New or Used
Year
Make
Model
Engine Size
Registration Number
Type of Use
Purchase Price
Date of Purchase
-
Day
-
Month
Year
Date
Market Value
Please Select
Yes
No
Agreed Value
$
Type of Cover
Please Select
Comprehensive
Fire/ Theft & Third Party
Third Party Only
Cylinders
Please Select
4 Cylinders
6 Cylinders
8 Cylinders
No Claim Bonus
%
Parked Daytime
Method
Postcode
Parked Overnight
Method
Address
Accessories
Value
1
2
3
4
5
Modifications
Value
1
2
3
4
5
Driver Details
Driver #1
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Year Obtained Licence
Percentage of Use
%
Driver #2
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Year Obtained Licence
Percentage of Use
%
Driver #3
Name
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Year Obtained Licence
Percentage of Use
%
Claims History
For last 5 years (include property damage, theft & fire claims)
Claim #1
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #1
Amount
Claim #2
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #2
Amount
Claim #3
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #3
Amount
Duty of Disclosure
Yes or No
Is the motorcycle fitted with any non – standard security devices? If yes please give details below.
Yes
No
Does the motorcycle have any existing damage, defects (rust, hail or unrepaired body damage)?
Yes
No
Does the motorcycle have any mechanical or other problems which will make it unsafe?
Yes
No
Do any of the drivers (who drive more than 10% of the time) have less than 2 years driving experience?
Yes
No
Was the motorcycle manufactured from a kit, reconstruction from parts or homemade? If yes give details below.
Yes
No
Has the insured or any drivers ever been declared bankrupt or been placed in receivership?
Yes
No
Has the Insured or any drivers ever had insurance cancelled, declined or special conditions imposed?
Yes
No
Has the Insured or any drivers ever been charged or convicted of any criminal offence including drug use, driving under the influence or any driving offence, speeding infringements, fraud, arson or theft?
Yes
No
Has the insured or any driver of the vehicle had their licence cancelled, suspended or endorsed?
Yes
No
Does the Insured or drivers suffer from any physical or mental disability (excl. eyesight corrected by lens)?
Yes
No
If Yes, Provide Full Details
Broker Recommendations
Print Form
Submit
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