EmailMeForm
NB Endorsement Request Form
10020 12th Avenue North Battleford, SK S9A 3A4
Toll-Free Phone: 1-866-979-2747
Email: nbtoys@oasisins.ca
Brokerage Details
Brokerage Name and branch
*
Broker's Name
*
Broker's Email Address
*
Phone Number
*
###
-
###
-
####
Named Insured(s) Details
Named Insured(s)
*
Existing policy number
*
Enter membership numbers that apply to Named Insured(s)
New Brunswick Snowmobile Federation (NBSF)
New Brunswick All-Terrain Vehicle Federation (NBATV)
New Brunswick Dirt Bike Riders Association (NBDRA)
Endorsement Details
Endorsement Effective Date DD/MM/YYYY
*
Type of Endorsement
*
Add vehicle only
Replace with an existing unit
Other types of requests can be sent in the body of an email to nbtoys@oasisins.ca
Extra Endorsement Notes (if applicable)
New Unit Details
Type of Unit
*
All Terrain Vehicle (ATV, UTV, Side by Side)
Snowmobile
Dune Buggy
Trail Bike
SnoBear, SnoBus,
Sherp/Atlas or Argo
Snow Groomer
Other (make notes in comments of the type)
Year
*
Make
*
Model
*
CC's
*
VIN
*
*
Yes
No
Will this unit be used/stored in NB at least 60% of the time?
Will this unit be used in racing/speed events?
Does this unit have existing damage?
Is unit within 25km of an imminent threat of damage?
Is this a dual use trail bike? (if yes, provide % of on hwy use in notes)
Is this a trail bike with tracks for winter use?
Will this unit be used for business use?
*
No
Yes , details below
Yes, details on file *no need to fill out remainder of business use details
If Yes to Business use, complete the following details.
Type of Industry
Percentage of time unit used for business?
Will multiple operators use the unit for business?
How many KM driven anually?
Please provide details of how the unit will be used specifically in the business?
Does the unit have performance enhancing equipment modifications?
*
None
Factory Installed turbo
Aftermarket Installed Turbo *Will require invoice/inspection of install by licensed mechanic
Other *provide details in the comments box at bottom of page
Where is the normal area of use for the unit?
*
Where is the unit stored and what precautions are taken?
*
Principal Operator Information
First Name
*
Last Name
*
Information same as on file *not required to complete additional PO details.
Date of Birth
DD
/
MM
/
YYYY
Drivers Licence Number
Years of Riding Experience
Number of convictions in the last three (3) years
Number of claims in the past five (5) years
Safety Training- List course name if PO has taken any safety training courses
ATV Training
Snowmobile Training
Trail Bike Training
Additional Operator Information
Last Name
First Name
Date of Birth
DD
/
MM
/
YYYY
Years of Riding Experience
Number of convictions in the last three (3) years
Number of claims in the past five (5) years
Drivers Licence Number
Coverage Information
Third Party Liability- Uninsured, HSL, DCPD and Accident Benefit automatically included.
*
Declined
$500,000
$1,000,000
$2,000,000
Physical Damage
*
Declined
All Perils
Comprehensive
Insured Value
$
Dollars
.
Cents
See underwriting guide for assistance.
Deductible
*
N/A
$500
$1000
$2500
$5000
If unit valued over $40,000 minimum $1000 deductible will apply.
Endorsements
*
None
SEF44- Family Protection
SEF43R- Limited Waiver *must complete section below.
Rider Plus Enhancement
Limited Waiver details *Only required if purchasing this endorsement.
I confirm the unit is brand new (original owner, purchased from dealer)
Yes
No
Demo
Delivery Date
DD
/
MM
/
YYYY
Purchase Price
$
Dollars
.
Cents
See underwriting guide for assistance
Bill of Sale
Add File
Lienholder Information (If applicable)
Lienholder Name
Lienholder Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Removal Unit Information (If Applicable)
Year
Make
Model
Vin#
Additional Information (if applicable)
Additional Details (if applicable)
Additional Supporting Documentation
Add File
