Motorcycle insurance

Please take a moment to fill out this form and one of our brokers will contact you shortly to offer you a quotation or discuss your requirements further.
Title	*	[Please select] Mr Mrs Miss Ms
First name	*
Second/middle name
Surname	*
Date of birth	*
Place of birth	*
Sex	*	[Please select] Male Female
What is your occupation	*
Are you self employed	*	[Please select] Yes No
What is your employers business
Name or number of your home	*
Postcode	*
Do you own or rent this property	*	[Please select] I own it I rent it
E-mail address	*
Daytime contact number (including code)	*
Evening contact number (including code)
Mobile contact number (including code)
How did you hear about us	*	[Please select] Existing client Past client Recommendation Radio advert Press advert Yellow pages Facebook
When do you need this insurance to start	*
Make of bike	*
Model of bike	*
CC of bike	*
Year of make	*
Value	*
Registration number (if known)
Who owns this vehicle	*	[Please select] I do Parent Spouse Someone else owns it Lease/hire company Its a company vehicle
What type of licence do you have	*	[Please select] Full UK/CI/Isle of Man Full EU Provisional Other
When did you pass your test dd/mm/yyyy	*
Where do you park the bike overnight	*	[Please select] Garage Driveway Public road or car park
What do you use the bike for	*	[Please select] Social domestic and pleasure including commuting Social domestic and pleasure excluding commuting Social domestic and pleasure and business use by me Social domestic and pleasure and business use by me and my spouse Business use by all drivers
Who do you want to be insured to ride this bike	*	[Please select] Just me Me and my spouse Me and one other riders Me and 2 other riders Me and 3 other riders Me and 4 other riders
What is the age of the youngest rider who may use this bike	*
Has anyone who rides this bike made a claim in the last 5 years	*	[Please select] Yes No
Has anyone who rides this bike had a driving conviction in the last 5 years	*	[Please select] Yes No
How many years no claims discount do you have	*	[Please select] None 1 year 2 years 3 years 4 years 5 years More than 5 years
What do you think your annual mileage is	*	[Please select] Less than 5 000 Less than 10 000 More than 10 000
What level of cover do you want	*	[Please select] Comprehensive Third party fire and theft Third party only
Do you want to insure your excess?	*	[Please select] Yes No
What is this?
Do you want 24 hour UK, Channel Island, Isle of Man and European breakdown cover?	*	[Please select] Yes No
Who are your current insurers
What is your current premium
Material facts
A material fact is any piece of information that might affect the underwriters decision to provide you with insurance. You are obliged to advise us of any material facts. ,Examples of material facts include but are not limited to: * Non motoring convictions for fraud, theft or dishonesty * Prior claims or events, or any special terms or conditions that have been applied by previous insurers * Motor insurance – motoring convictions, medical conditions, non standard modifications * Travel insurance – pre existing medical conditions, hazardous activities * Home insurance – unusual construction, let or part let properties, extended unoccupancy. This obligation applies at the time you arrange insurance and extends to any change in circumstances whilst you are insured with, If material facts come to light once your policy has started, your insurer has the right to refuse payment for all or part of any claim you may make.
Privacy and Data Protection
The Rossborough Group holds your details in accordance with relevant Data Protection Law in the UK, Isle of Man and Channel Islands. Some or all of the information you supply to us in connection with your insurance proposal will be held on computer and may be passed to insurance companies for underwriting and claims purposes. In addition, we may use some of the information to advise you of other products and services offered by the Rossborough Group. If you do not wish to receive such details please contact our Compliance Officer by emailing nquick@rossboroughgroup.co.uk.
Terms of business
Rossborough Terms of Business can be found here.
Credit checks
To make sure you get the best offer from insurers, now or at any renewal or at any time and to protect their customers from fraud and to verify your identity, they may use publicly available data which they obtain from various sources, including a credit reference agency and other external organisations. Their search will appear on your credit report whether or not your applications proceed. By continuing with this form we will assume you are happy with us to proceed on this basis.
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R A Rossborough (Insurance Brokers) Limited is regulated by the Jersey Financial Services Commission