First Name: Required Field
Surname: Required Field
State: Required Field

Contact Details (During Business Hours)

Phone: Required Field
Mobile:
Email: Required Field

Motorbike Details

Level of Cover: Comprehensive Third Party Property Damage
Cover Type: Market Value Agreed Value

Garaging Details

Suburb: Postcode:

Rider Details

Rider Gender Age Year Licence Obtained Owner of this Motorbike? Registered Owner of another Motorbike?
Rider 1 Yes No Yes No
Rider 2 Yes No Yes No
Rider 3 Yes No Yes No

No Claim Bonus Level of Motorbike Owner Years NCB Held
Have any of the nominated riders had an at-fault collision claim in the last 5 years? Yes No
Have any of the nominated riders had a claim in the last 5 years? Yes No

Motorbike Details
Motorbike Make
Motorbike Model
Motorbike Year
Motorbike Sum Insured (excluding accessories)
Accessories Sum Insured
Are any security devices fitted to the motorbike?
What financing does the motorbike have?
How is the motorbike to be used?
Garaging Type at Night
Estimated Annual Distance Travelled

Policy Options

Do you wish to take excess-free headlight cover? Yes No
Do you wish to take car rental following an accident? Yes No
Do you require No Claim Bonus protection? Yes No
Do you require Restricted Rider discount? Yes No
Do you require Named Rider option? Yes No
Do you require Riding Gear coverage? Yes No
Do you require Additional Voluntary Excess? Yes No

Comments or Questions:
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