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Motorcycle Insurance
Name:
Email Address:
Address:
City:
Province:
Postal Code:
Phone Number:
Age:
M1 License Date:
/ /
yyyy   mm   dd
M2 License Date:
/ /
yyyy   mm   dd
M License Date:
/ /
yyyy   mm   dd
Did you take a Riders Training Course:
Yes     No
Any Tickets?
Yes     No
Any claims in last 6 years?
Yes     No
What Coverage are you looking for
Liability Limit:
Collision Deductible amount:
Comprehensive Deductible amount:
Specified Perils Deductible amount:
Year, make and model:
Value of Bike:
Modified or Customized:
Yes     No
Previous Insurance Company:
Do you belong to any Riders Associations or Clubs?
Yes     No
 

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