Staebler Insurance Brokers

The Best Insurance Is An Insurance Broker

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

Any tickets?

Yes

Any claims in last 6 years?

Yes

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

Previous Insurance Company:

Do you belong to any riders associations or clubs?

Yes

Disclaimer:

H.L. Staebler Company Limited is not responsible for instructions not received and acknowledged by a confirmation via e-mail or phone call. By submitting this form, you acknowledge that you are the policyholder and the events described on this form are truthful. Only the person named as the insured in the policy documents can submit a claim report on this policy. All policy terms and conditions apply, subject to policy status at time of submission.