BIKE INSURANCE QUOTE
Title

First Name

Surname

Address

Postcode

Telephone Number

Email

Are you the member of a motoring club

Yes No

If YES, please name the club

2. Main Rider (Please give details of all persons including yourself who will or may ride the Motorcycle)
Title

First Name

Surname

Date of Birth (dd/mm/yyyy)
Occupation (including part-time)
Employer's business
Self-employed
Yes  No
Current continuous period of UK residency
(years)
Type of bike licence
If EU or other please specify country issued
Date bike test passed (dd/mm/yyyy)
 
Relationship to proposer
Do you hold a car licence
If EU or other please specify country issued
Date Driving test passed (dd/mm/yyyy)
3. Adding other Riders (Please go on to question 4 if you are the only rider)
Add another rider (Additional Rider ONE)
Yes No     
Title

First Name

Surname

Date of Birth (dd/mm/yyyy)
Occupation (including part-time)
Employer's business
Self-employed
Yes  No
Current continuous period of UK residency
(years)
Type of bike licence
If EU or other please specify country issued
Date bike test passed (dd/mm/yyyy)
Relationship to proposer
Do you hold a car licence
If EU or other please specify country issued
Date Driving test passed (dd/mm/yyyy)
Add another Rider (Additional Rider TWO)
Yes No      
Title

First Name

Surname

Date of Birth (dd/mm/yyyy)
Occupation (including part-time)
Employer's business
Self-employed
Yes  No
Current continuous period of UK residency
(years)
Type of bike licence
If EU or other please specify country issued
Date bike test passed (dd/mm/yyyy)
Relationship to proposer
Do you hold a car licence
If EU or other please specify country issued
Date Driving test passed (dd/mm/yyyy)
Add another Rider (Additional Rider THREE)
Yes No    
Title

First Name

Surname
Date of Birth (dd/mm/yyyy)
Occupation (including part-time)
Employer's business
Self-employed
 Yes  No
Current continuous period of UK residency
 (years)
Type of bike licence
If EU or other please specify country issued
Date bike test passed (dd/mm/yyyy)
Relationship to proposer
Do you hold a car licence
If EU or other please specify country issued
Date Driving test passed (dd/mm/yyyy)
4. Motorcycle details
Make and Model
Cubic Capacity cc
Year of manufacture
Fuel Type
Annual mileage
Value £
Registration Number
Is the motorcycle owned / registered in your name
Yes   No 
If NO please give details
Where is the motorcycle kept
Postcode of where the motorcycle is kept

Has the motorcycle been modified or tuned

Yes No 
If YES please give details
Has the motorcycle a security device

Yes No   

If YES please state type

Does the motorcycle have a permanently fitted sidecar

Yes No

How many bikes are owned or used by you
(and members of your household)

Please give details

Have you passed a Motorcycle Proficiency Test

Yes No

If YES please specify which one
When is your renewal date (dd/mm/yyyy)

No Claims Bonus available to use on this vehicle

Would you like bonus protection if eligible
Yes   No 
Type of cover required
5. In addition to social, domestic and pleasure purposes, will the vehicle be used:
a
to and from one place of work by main rider?
 Yes No
b
for business purposes by main rider?
 Yes  No
c
for business purposes by any person other than main rider?
 Yes No
d
for commercial travelling, carriage of goods, hire, reward or motor trade purposes?
 Yes No
If you answered YES to any of question 5, give further details in the box below.
giving as much information as possible.

6. Does any person who will drive suffer from any disabilities and/or medical conditions?

Disabilities

Yes   No 

If YES please state condition

Details of any medication taken
Is your licence restricted
Yes   No 
Have DVLA been advised
Yes   No 
7. Has any person who will drive been involved in a motor accident or claim in the past 5 years?
Accident 1 - Yes    No

Which named rider was involved?

What was the date of this accident?  (dd/mm/yyyy) 

Select accident description

Add further details

Were ALL of these costs reclaimed from a third party?  Yes   No   Pending

If No or Pending what were your own and third party costs claimed?

Owed to Rider Costs £   Owed to Third Party Costs £

Has this rider any convictions or fixed penalty fines related to this accident? Yes   No

If YES

What was the date of the conviction?  (dd/mm/yyyy) 

What is the conviction code?

What fine amount was imposed? £

How many months ban was imposed? months

Accident 2 - Yes    No

Which named rider was involved?

What was the date of this accident?  (dd/mm/yyyy) 

Select accident description

Add further details

Were ALL of these costs reclaimed from a third party?  Yes  No  Pending

If No or Pending what were your own and third party costs claimed?

Owed to Rider Costs £   Owed to Third Party Costs £

Has this rider any convictions or fixed penalty fines related to this accident?  Yes   No 

If YES

What was the date of the conviction?  (dd/mm/yyyy) 

What is the conviction code?

What fine amount was imposed? £

How many months ban was imposed? months

Accident 3 - Yes    No

Which named rider was involved?

What was the date of this accident?  (dd/mm/yyyy) 

Select accident description

Add further details

Were ALL of these costs reclaimed from a third party?  Yes   No   Pending

If No or Pending what were your own and third party costs claimed?

Owed to Rider Costs £   Owed to Third Party Costs £

Has this rider any convictions or fixed penalty fines related to this accident?  Yes   No 

If YES

What was the date of the conviction?  (dd/mm/yyyy) 

What is the conviction code?

What fine amount was imposed? £

How many months ban was imposed? months

Accident 4 - Yes    No

Which named rider was involved?

What was the date of this accident?  (dd/mm/yyyy) 

Select accident description