EmailMe Form - Pedal Power Quote Form

10020 12th Avenue North Battleford, SK S9A 3A4
Toll-Free Phone: 1-866-979-2747
Email: pedalpower@oasisins.ca

Eligibility Questions

*

	No	Yes
Do you compete in competitive events? (Note: This does not make you ineligible for coverage. You are not covered while practicing for or participating in an event, unless you've purchased the competitive event endorsement.)
Does the operator suffer from any illness, medical condition, or mental or physical disability which might affect the safe operation of a bicycle?
Have you ever had a recreational vehicle policy refused, restricted or cancelled?
Are your units kept in Canada?
Do you have a Canadian mailing address?
Have you had any bike thefts or claims in the past 3 years?
Will any of the units added on this application be used for business use?
Are any of the units to be insured under this policy gas powered?
Will you be traveling with the unit to be insured, outside of Canada and the USA?
Will you be traveling with the unit to be insured, to the USA for longer than 6 months?
Will any of the units added on this application be a Scooter or Low Speed Motorcycle?
Are any operators younger than 16 or older than 84 years?

Personal Information

Owner #1 *

First Last

Owner #2 (if applicable)

First Last

Email *

Phone *

### - ### - ####

Address *

Street Address City State / Province / Region Postal / Zip Code

Membership Information

Membership *

Membership Number

Unit Information

Unit Type *

Note, coverage is only available for units with a maximum output of 500 watts and a top speed of 32 km/hr. Units exceeding these specifications are not eligible for coverage.

Year *

Make *

Model *

Serial Number *

Principal Operator *

First Last

Date of Birth *

DD / MM / YYYY

Where is the normal area of use? *

Where is the unit stored and what precautions are taken? *

Coverage Information

Proposed Effective Date *

DD / MM / YYYY

Please note, we can't backdate effective dates.

Third Party Liability *

Accident Benefits *

Physical Damage *

If unit was purchased used, provide current market value, including fixed accessories (Also include HST for ON, NS, NB, NFL, PEI)

If purchased new and within 3 years old, attach a bill of sale (required)

Endorsements (Check off all that are required) *

None

Business Use

Travel Outside of Canada or the U.S.

Competitive Event Extension (Covers you while practicing for or competing in competitive events)

Lienholder Information (if applicable)

Lienholder Name

Lienholder Address

Street Address City State / Province / Region Postal / Zip Code

Unit #2 Information (if applicable)

Operator Name

First Last

Date of Birth

DD / MM / YYYY

Gender

Unit Type

Year

Make

Model

Serial Number

Where is the normal area of use?

Where is the unit stored and what precautions are taken?

Unit #2 Coverage Information (if applicable)

Third Party Liability

Accident Benefits

Physical Damage

If unit was purchased used, provide current market value, including fixed accessories (Also include HST for ON, NS, NB, NFL, PEI)

If purchased new and within 3 years old, attach a bill of sale (required)

Endorsements (Check off all that are required)

None

Competitive Event Extension (Covers you while practicing for or competing in competitive events)

Business Use

Travel Outside of Canada or the U.S.

Unit #2 Lienholder Information (if applicable)

Lienholder Name

Lienholder Address

Street Address City State / Province / Region Postal / Zip Code

Claim Information

How many bike claims in the last 3 years *

Enter claims details (if applicable)

	Date of Loss (DD/MM/YYYY)	Type of Claim (Theft, Collision, Liability)	Payout Amount
Claim One
Claim Two
Claim Three
Claim Four

Additional Information (if applicable)

Additional Supporting Documentation (if applicable)