EmailMeForm
Pedal Power Quote Form
This form is for direct client use only.
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 any unit(s) on this policy be Electric Assisted?
If electric assisted, will any unit(s) be over 500 watts and/or over 32km maximum speed?
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?
Are any of the units to be insured located within 25 km of an imminent threat of damage (e.g., fire, flood, earthquake aftershocks, etc.)?
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
*
Please select
None
International Mountain Bicycling Association of Canada
Canadian Cycling Association
Triathlon Canada
Hub Cycling
Meraloma Bike Club
Membership Number
Unit Information
Unit Type
*
Please select
Pedal Bike
Electric Bike
Scooter Style Electric Bike
Motorcycle Style Electric Bike
Recumbent Bike
Golf Cart
Mobility Scooter
Electric Wheelchair
Electric Skateboard/Segway/Electric Kick Scooter
Trishaw
Enclosed Mobility Scooter
Snowdog
Velomobile
Other (make notes in comments of the 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
*
Please select
None
$1,000,000
$2,000,000 (Only eligible on Golf Carts)
Accident Benefits
*
Please select
None
Basic
Enhanced
Physical Damage
*
Please select
None
All Perils
Comprehensive (Only eligible on Golf Carts)
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)
Add File
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
Please select
Female
Male
Unit Type
Please select
Pedal Bike
Electric Bicycle
Scooter Style E-Bike
E-Skateboard/Segway/Electric Scooter
Motorcycle Style E-Bike
Golf Cart
Trishaw
Mobility Scooter
Electric Wheelchair
Recumbent Bike
Enclosed Mobility Scooter
Snowdog
Velomobile
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
Please select
None
$1,000,000
$2,000,000 (Only eligible on Golf Carts)
Accident Benefits
Please select
None
Basic
Enhanced
This covers losses incurred while you are getting on, alighting from, operating or riding, including whilst riding as a passenger, on an insured unit during the policy term.
Please note: Only available if Third Party Liability is purchased.
Physical Damage
Please select
None
All Perils
Comprehensive (Only eligible on Golf Carts)
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)
Add File
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
*
Please select
None
One
Two
Three or more
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)
Add File
