Conestoga Logo Conestoga Insurance Brokers Ltd
Request for Motorcycle Insurance Quote
Ontario Residents Only!
 
Please provide ALL applicable information in order for us to promptly complete your request! 

Applicant

Name:     E-mail:  
Address:    Postal Code:  
City:   Phone:  
Please make sure your contact information is accurate so that we can contact you!

Driver Information
  If Licensed after Mar 31 1994
  
Sex Date of Birth
   Date of M1 License Date of M2 License Driver Training
Male Female
DD/MM/YYYY 		 
 
MM/YYYY
MM/YYYY
The M1 & M2 fields are not necessary if you received your license prior to April 1st 1994
as Graduated Licensing did not come into effect untill that time.

Motorcycle Information Coverage
Year Make Model CC's Liability Amt Comp Deductible Fire & Theft Deductible Collision Deductible Value in Dollars
    e.g Honda    e.g Gold Wing    e.g 350    e.g $15,000 


How many years have you been insured        
If you are NOT currently insured, How many Months have you been uninsured?

Name of Current Insurance Company if any:  
      Renewal Date

Have you ever been cancelled for non-payment?       

Have claims been made by ANY of the drivers in the past 6 years?         
      If Yes, please explain.
      

Do you have moving traffic violations such as speeding, seatbelts, dangerous driving in the last 3 years?       
      If Yes, please explain.
      


Please provide any additional information that you feel is necessary in order to serve you better.