Motorcycle Insurance Quote Request Form

DTG Guarantee: Dalton Timmis is committed to providing the best service possible in conjunction with the best premiums available.

Please select the program you are interested in:
Classic Cruiser Custom

* Required field

Rider & License Information

Name*:

Email Address*:

Home Address*:

City*:

Province*:

Postal Code*:

Phone Number*:

Fax Number:

Date of Birth*:
year: (yyyy)

License Type and Date Received*:
year: (yyyy)

Date Insurance Required*:
year: (yyyy)

Did you take a Riders Training Course?
Yes No

Do you belong to any Riders Associations or Motorcycle Clubs?
Yes No

If yes, please explain:

Your auto/motorcycle license number*:

Do you currently hold Motorcycle Insurance?
Yes No

If yes, please name insurance company and length of time insured ( you may qualify for further discount);

Any tickets in the last 3 years?
Yes No

If yes, please explain, including violations, dates etc:

Any claims in the last 6 years?
Yes No

If yes, please explain details including dates:

Please list other motorcycle licensed operators in your Household. (names, age, licence level etc...)*:

(If you have more than 2 bikes, please list particulars in the additional comment section)

	Bike #1*	Bike #2
Year, Make, and Model*:
VIN #:
How many cc's*:
Purchase Date*:
Current actual cash value*: (Appraisal Including Taxes)
Any anti-theft device? If yes, please explain:
Modified or Customized?: (if yes, appraisal required)	Yes No	Yes No
Intended Use:

Additional Comments :

What coverage are you looking for?

Would you like a quote on your home and auto?
Yes No

How did you hear about us?

Please specify if you selected Interenet or Other

We will be happy to give you a call, as we require additional information to assist you.

Disclaimer
If you prefer, you may contact one of our Motorcycle Insurance Specialists at 1-866-758-7869