EmailMe Form - Pedal Power Endorsement Request Form

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

Brokerage Details

Brokerage Name and Branch *

Broker Contact Name *

Broker Contact Email Address

Phone Number *

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

Named Insured(s) Details

Named Insured(s) *

Existing Policy Number *

Membership *

Membership Number

Endorsement Details

Endorsement Effective Date *

DD / MM / YYYY

Type of Endorsement *

Extra Endorsement Notes (if applicable)

Unit Details

If you're adding a new unit, enter the unit details below. If you're updating an existing unit, enter the details of the unit these changes apply to.

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 *

Wattage *

Speed (km/hr) *

Serial Number *

Principal Operator *

First Last

Date of Birth *

DD / MM / YYYY

Gender *

Coverage Information

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)

Accessories or Upgrades (if applicable)

Value of Accesories or Upgrades (if applicable)

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)

If yes to business use, please complete the following details

Unit(s) #
% of Business
% of Pleasure
How many KM driven anually?

Please provide details of how the unit will be used specifically in the business.

If yes to travel outside of Canada or the U.S., please complete the following details

Country or countries you're travelling to
Date of Departure (DD/MM/YYYY)
Date of Return (DD/MM/YYYY)

Please provide details of what the travel is for.

Lienholder Information (if applicable)

Lienholder Name

Lienholder Address

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

Removal Unit Information (if applicable)

Year

Make

Model

Serial Number

Additional Information (if applicable)

Additional Supporting Documentation (if applicable)