*  indicates a required field entry

Your Full Name:

Address:

City:

Province:

Postal Code:

Phone Number & Area Code:

E-mail Address: (only one address please)

Fax Number:

Your Date of Birth: (M/D/Y)

Gender:

Date Insurance Required:

Your Ontario auto / motorcycle licence number?

Do you currently hold Motorcycle Insurance?

If yes, please name Insurer, length of time insured, and any claims in the last 3 years:
(advise reasons for any policy cancellations)

Do you have any moving violation convictions (tickets) in the last 3 years?

If "no", please enter "none"
If "yes", please explain (dates, violations, etc.):

Have there been any claims/accidents on motorcycle or auto in last 6 years?

If "no", please enter "none"
If "yes", please explain (dates, details, etc.):

Please list other operators of Motorcycles in your household (names, ages, motorcycle licence level/class held etc):

• Motorcycles over twenty-five years old are excluded from this Program
• THE FOLLOWING MOTORCYCLES ARE SURCHARGED BY JEVCO
  And the premiums will average $1,600 to $2,100 - click here for list

Quote Options:

Third Party Liability:

Direct Compensation - Property Damage
(deductible must NOT exceed motorcycle value)

Collision (see notes for Harleys / Indian)

Comprehensive / Specified Perils (see notes for Harleys / Indian):

Group Discount Rate?
(see approved group list):

Policy Payment Arrangement (see notes):

How Did You Find Us?

Additional Comments:
(Certain Harley & Super Sport bikes require proof of installation of approved alarm system to qualify for Specified Perils / Comprehensive cover)