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Motorcycle Insurance Quote
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If other please specify:

PLEASE NOTE

***** We cannot offer terms for convictions of a sexual nature involving minors ***** (including illegal download/possession of indecent images)

About you
Title
First Name
Surname
House Name / Number
Full Address
Postcode
Email Address
Telephone Number
Sex
Date of Birth
Marital Status
Occupation
Type of business
Employment Status
Marital Status
Are you a Homeowner?
Type of Licence
Have long have you held this licence?

When did you Pass you CBT?
Are you a mermber of BMF or MAG?

About your convictions

(please list 1,2,3 in each section if you have more than 1 conviction)

Date of Offence

Date of Conviction

Type of Conviction

(e.g GBH, Common Assault)

Sentence given by court

(e.g. 5 years custodial or 100 hrs community service)

Sentence actually served

(e.g. served 2 years then 3 months on tag)

Description of Incident

(Please give as much information as possible)

Mitigating Circumstance

(e.g. had drink problem at time now recovering alcoholic etc.)

Bike Details
Make
Model
Type
Engine Size
Year Bike First Registered
Registration number
(if known)
Current Value
Date of Purchase
Please give details of any modifications
Where is the vehicle kept overnight?
Please give details of any security devices used
Are you the registered owner & keeper?
If you require cover for more than one bike on your policy, please give full details of any additional bikes here
Cover Required
Cover Required
Do you require 'Driving other Bikes' extension
Ho many years no claims bonus do you have on this vehicle?
Protected / Guaranteed bonus required?
How many years have you been continuously insured on a motorbike?
What is the largest cc motorcycle you have been insured on in the last 5 years ?
Use of vehicle
What is your approximate annual mileage for :
Pleasure Use
Business Use
Driving Restriction?
Please state name of MAIN driver
Additional Driver 1
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?
Additional Driver 2
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?
Additional Driver 3
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?
Additional Driver 4
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?
Accidents/Driving Convictions

Please give FULL details below of any claims against your policy or on the records of named drivers in the last FIVE years. (Please include Date, any injuries, whether bonus was affected)

Please also list below any motoring convictions for yourself or any named drivers in the last FIVE years. (Please include Dates of convictions, conviction codes, fines/penalty points & any bans incurred)
Date Cover to commence
Current renewal premium, if applicable
Current Insurer, if applicable
Additional Information

Please add any information you feel may affect the quotation.

Call us now on...0800 440 24 14

‘Insurable’ is a trading name of Gothic Insurance Brokers Ltd who are are authorised & regulated by the Financial Services Authority, Firm Number 300031
Registered Trading address : Gothic House, Station Road, Old Harlow, Essex, CM17 0AP