Mayfair Online - Insurance Consultants

Performance Bike Direct: Motorcycle Quote Form

In order for us to process this form successfully, please fill in exact details. Also include a valid email address.

Full Name:

D.O.B.

Address:

Postcode:

Daytime Phone No.:

Work Phone No.:

Mobile Number:

E-Mail Address:

IF YOU ONLY NEED INFORMATION about this type of insurance and do not want to fill out this entire form, please fill out the next box and tell us what information you require. Then click on 'GO' button, which will take you to the bottom of this page. You should then click on the 'SUBMIT' button which will send us your details. (If this does not apply, please carry on with your details.)

Information required: Click on submit at base of page.

Vehicle:

Make:

Model:

Engine Size:

Registration:

Fuel:

Transmission:

Year:

Type(Fireblade)

Value:

Alarm Fitted:

Yes No

Model Fitted:

Fitted By:

Immobiliser:

Yes No

Model Fitted:

Fitted By:

Parking:

Registered Owner:

Other, Please state:

Who will ride:

Age of youngest rider:

Length of Policy:

Proposer Details:

Sex:

D.O.B.:

Riding Status:

Occupation:

Business:

Status:

Employed:

Personal Details:

Marital Status:

Length of residency:

Country of origin:

Licence type:

Length licence held:

CBT obtained:

Country Issued:

Vehicle Issued:

All policies have Social, Domestic and Pleasure use, to and from one permanent place of work. Yes No

Extended use:

Yes No

Personal business use: Yes No

Employers business use:

Yes No

Carriage of Goods:

Yes No

Side Car:

Yes No

Pillions:

Yes No

Turbo/Superchip:

Yes No

Private Mileage:

Business Mileage:

Home Owner:

Yes No

Renewal Date:

Contents sum insured:

Buildings sum insured:

Smoker

Yes No

Drinker

Yes No

Do you have use of any other vehicles:

Yes No

Whose motor vehicle do you use:

Other:

Renewal date:

Have you suffered any loss during the past 5 years regardless of blame. This includes Loss by theft, Accident, Fire, Malicious, Accidental. Yes No

How many accidents have you been involved in:

Date of loss:

Type:

Damage to your vehicle:

Damage to third party

Did your insurers recover all losses:

Yes No

Was your No Claims bonus affected:

Yes No

Whose policy was this claim under:

Other:

Your fault:

Yes No

Description:

Do you have motoring convictions in the past 11 years:

Yes No

How many offences have occurred:

Date of Offence:

Date of Conviction:

Fine:

Points:

Length of Ban:

Do you have any disabilities or Medical infirmities:

Yes No

Type of Infirmity:

Other Infirmity:

Have DVLA been notified:

Yes No

Has your riding licence been restricted:

Yes No

How long have you had the infirmity:

Has your vehicle been adapted:

Yes No

Cover Details:

Cover:

Years NCB:

Type of NCB:

Protected NCB:

Yes No

Parking Post Code:

Renewal Date: