Gothic Insurance Brokers Ltd
Gothic House
Station Rd, Old Harlow
Essex CM17 0AP

Tel – 01279 429024
Fax – 01279 433383
Email – enquiries@gothicinsurance.com

Motorcycle Insurance Quote

Quotes emailed to you within minutes (during office hours)

Where did you hear about us?

If other please specify:

About you
Title
First Name(s)
Surname
Full Address (If vehicle is not kept at this address please state so in additional information section)
Postcode
Email Address
Telephone Number
Sex
Date of Birth
Occupation
Type of Business
Employment Status
Marital Status
Are you a Homeowner?
Type of Licence
Have long have you held this licence?
When did you Pass you CBT?
Are you a mermber of BMF or MAG?

Bike details
Make
Model
Type
Engine Size
Year Bike First Registered
Registration number (if known)
Current Value
Date of Purchase
Please give details of any modifications
Where is the vehicle kept overnight?
Please give details of any security devices used	e.g. Datatool alarm/immob. e.g. Oxford Chain e.g. Ground Anchor e.g. Alphadot tagging
Are you the registered owner & keeper?
If you require cover for more than one bike on your policy, please give full details of any additional bikes here

Cover Required
Cover required
Do you require 'Driving other Bikes' extension
Ho many years no claims bonus do you have on this vehicle?
Protected / Guaranteed bonus required?
How many years have you been continuously insured on a motorbike?
What is the largest cc motorcycle you have been insured on in the last 5 years ?
Use of vehicle
What is your approximate annual mileage for :
Pleasure Use
Business Use
Driving Restriction?
Please state name of MAIN driver

Additional Drivers : 1st Named Rider
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?

Additional Drivers : 2nd Named Rider
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?

Additional Drivers : 3rd Named Rider
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?
Additional Drivers : 4th Named Rider
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?

Accidents / Convictions

Please give FULL details below of any claims against your policy or on the records of named drivers in the last FIVE years. (Please include Date, any injuries, whether bonus was affected)

Please also list below any motoring convictions for yourself or any named drivers in the last FIVE years. (Please include Dates of convictions, conviction codes, fines/penalty points & any bans incurred)

Additional Information
Please add any information you feel may affect the quotation.

How would you like to be contacted?

01279 429024

Authorised & Regulated by the
Financial Service Authority
Firm Number: 300031

Gothic Insurance Brokers Ltd. is registered in England. Company Reg. Number 880423. Registered Office: Gothic House, Station Rd, Old Harlow, Essex CM17 0AP