* First Name:

* Surname:

QLD NSW ACT VIC SA NT WA TAS

* Rider Date of Birth:

(dd/mm/yyyy)

Phone Email

* Make:

* Full Model details:

* Year of Model:

* Capacity:

* Registration Number:

* Engine Number:

* Value / Sum Insured:

Private Dealer

* What was the Purchase date?

(dd/mm/yyyy)

* How many kilometres has your bike travelled?

* Does your bike have accessories?

Yes No

If yes, please list them and their value:

* What will be the Garaged Suburb?

* What will be the Garaged Post Code?

(post code of were the bike is to be kept)

* Is the Motorcycle under Finance?

Yes No

If yes, full Name of Financier?

* How many years have you been licensed?

less than 1yr 1-2 yrs 2-3 yrs 3-4 yrs 4-5 yrs 5-10 yrs 10+ yrs

* How many years riding experience have you had riding on this type of Cycle/Trike?

less than 1yr 1-2 yrs 2-3 yrs 3-4 yrs 4-5 yrs 5-10 yrs 10+ yrs

* Are you a Club Member?

Yes No

If yes, which Club?

BMW Ducati HRA HOG MRA Ulysses United Trikers Other

* How will your Cycle be used?

Private Business Tour Operator (we do NOT insure motorcycles for HIRE use)

* What will the Frequency of use be?

Regularly less than 8000 klms per year up to one day per week on average up to two days per week on average up to once per month on average On-Site only (exclude on-road use)

Who else will Ride your Cycle?

* Do you or any other person likely to ride your cycle have any health problems that could reasonably impair your or their ability to ride your Motorcycle?

Yes No

If yes, provide details?

* Is the Cycle kept in a Locked Garage when at home & not in use?

Yes No

* Is the Cycle Ridden to work?

Yes No

If yes, what Parking facilities are there?

On Street Off Street Public Car park Private Car park Secure Parking

* Do you hold current or recently expired (within 12 months) bike Insurance?

Yes No

If yes, what is your NCB Rating or %?

1 - 60% + 2 - 50% + 3 - 40% + 4 - 30% + 5 - 20% + 6 - 10% +

Previous or current Bike Insurance Company/Underwriter?

Previous or current Bike Policy Number?

Previous or current Bike Renewal Date?

(dd/mm/yyyy)

Previous or current Bike Premium Amount?

* Do you hold current or recently expired (within 12 months) car Insurance?

Yes No

If yes, what is your NCB Rating or %?

1 - 60% + 2 - 50% + 3 - 40% + 4 - 30% + 5 - 20% + 6 - 10% +

What type of Security Device(s) are fitted to the bike to prevent theft?

Disc/Wheel Lock
Steering Lock
Chain & Padlock
Cable Lock
Alarm

Self-Arming / Passive Immobiliser
Data Dot
Other

Specific Proposal/Underwriting Questions
In the last five years, have you or any other person likely to ride your motorcycle:

* NOT had regular motorcycle riding experience:

Yes No

* made a claim under a motorcycle or motor vehicle insurance policy:

Yes No

* had a motorcycle/vehicle accident:

Yes No

* had a motorcycle/vehicle burnt or stolen:

Yes No

* had other motorcycle/vehicle damage you have not claimed for or were not insured for:

Yes No

* a driving or riding offence, infringement, conviction, or any of these pending (only if 3 or more):

Yes No

* a driving/riding licence or permit cancelled, suspended, reduced to a probationary licence or special conditions imposed:

Yes No

* In 10 years a criminal conviction in insurance, commercial or property matters in relation to fraud, arson or theft:

Yes No

* an insurance application rejected:

Yes No

* a policy cancelled by an insurance company or a renewal refused:

Yes No

* special insurance conditions or imposed excesses:

Yes No

* a claim refused:

Yes No

Yes No

If you have answered “Yes” to any of the above questions, please provide details below:

We have to tell you about your duty of disclosure. When you answered our questions for this insurance quotation, you must have been honest and told us anything that you, or a reasonable person in the circumstances, would include in your answer. It is important that you understand you have answered the questions for yourself and anyone else to whom the questions apply. We may reduce or refuse to pay a claim, or cancel the policy, if you have not answered our questions in this way.
* Do you understand your duty of disclosure?
Please tick this box to acknowledge.

We are required to inform you that in relation to this motorcycle insurance product,
we are acting as agent of the insurer and not as your agent.
* Do you understand this?
Please tick this box to acknowledge.

* Denotes a required field

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