Motorcycle Insurance Proposal Form

 

 

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APPLY FOR HARLEYSURE

Online Insurance Quotation

Find out what HarleySure insurance can do for you!

Fill in this brief form and we'll promptly reply with a personalised quote!

Tell us about the person to be insured  
              
First name
Surname
I.D number
Date of birth
(only if you do not have an S.A. I.D number)
Street Address and Postal Code
E-mail address
Telephone no   
Licence type                 
Date of issue
Are you currently insured?    (yes or no, can get you more discounts)
Do you have any "No Claim" Bonuses?
How many motor losses within the last 3 years?
 
Tell us about the main rider (if not the above insured)
 
First name
Surname
I.D number
Licence type       
Date of issue
Date of birth (if you do not have an S.A. I.D number)
Street Address and Postal Code
E-mail address
Telephone no   
Do you have any "No Claim" Bonuses?
How many motor losses within the last 3 years?
 
Tell us a bit about your bike:
Year
Make     
Model
The value without extras    
The value with extras
Date cover is to commence
Do you need vehicle finance?
 

 

Where will the bike sleep at night?  
   
In a security complex
In a locked garage
Behind locked gates
   
Is there any riding gear you would like to insure?
 
  • Helmet
R
  • Jacket
R
  • Gloves
R
  • Pants
R
  • Boots
R
 
Do you want any optional extras?  
 
Medical Aid
Accidental Death and Injury Protection
Dental Insurance
Income Protection
 

 

 

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