EmailMeForm
MB Endorsement Request Form
10020 12th Avenue North Battleford, SK S9A 3A4
Toll-Free Phone: 1-866-979-2747
Email: mbtoys@oasisins.ca
Brokerage Details
Brokerage Name and Branch
*
Broker Contact Name
*
Broker Contact Email Address
*
Phone Number
*
###
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###
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Named Insured(s) Details
Named Insured(s)
*
Existing policy number
*
Enter membership numbers that apply to Named Insured(s)
Interlake Off Road Club
Grassroots Motocross (formerly Manitoba Motocross Association)
Snowpass/Snoman
ATVMB
Endorsement Details
Endorsement Effective Date DD/MM/YYYY
*
Type of Endorsement
*
Add vehicle only
Replace with an existing unit
Other (make notes below)
Extra Endorsement Notes (if applicable)
New Unit Details
Type of Unit
*
All Terrain Vehicle (ATV, UTV, Side by Side)
Snowmobile
Dune Buggy
Trail Bike
Golf Cart
SnoBear, SnoBus, Snow Groomer, SnoDog
Sherp/Atlas or Argo
Other (make notes in comments of the type)
Year
*
Make
*
Model
*
CC's
*
VIN
*
*
Yes
No
Will this unit be used/stored in MB at least 60% of the time?
Will this unit be used in racing/speed events?
Does this unit have tracks for winter use?
Does this unit have existing damage?
Is unit within 25km of an imminent threat of damage?
Is this unit used on public roads or highways?
Does the unit have an immobilizer (prevents the unit from being stolen)
*
None
Dess Key
Smart GPS Immobilizer (can disable unit remotely)
PIN Start System
Other (add type into comments section)
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
Coverage Information
Third Party Liability
*
Declined
$1,000,000
$2,000,000
Accident Benefits
*
Declined
Accepted
Physical Damage
*
Declined
All Perils
Comprehensive
Insured Value
$
Dollars
.
Cents
See underwriting guide for assistance.
Deductible
*
N/A
$500
$1000
If unit valued over $40,000 minimum $1000 ded will apply.
Endorsements
*
None
Rider Plus Enhancement
Replacement Cost Endorsement *must complete section below.
Replacement Cost details *Only required if purchasing replacement cost endorsement.
I confirm the unit is brand new (original owner)
Yes
No
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)
Details
Additional Supporting Documentation
Add File
