Applicant Details

Name*:

Date of birth*:

Address/Postal Code:

Occupation:

Email:

Phone*:

How did you hear about us?

Operator(s) Experience

Principal Operator Full Legal Name:

Date of Birth:

Operators under the age of 21: YesNo

Previous Insurer and Expiry Date:

Safety Course: YesNo

Any at fault vehicle accidents or claims in past 5 years: YesNo

Any off road vehicle claims in past 5 years: YesNo

Are you a member of any of the following groups? (Check and add Member #)
No GroupATVBCBCORMABCWFBCSFKimberly Wildlife and Wilderness ClubSmithers SnowmobileBordertown Sno-BomersWest Kootenay SnogoersCastlegar Snowmobile ClubGolden Snowmobile ClubKelowna Snowmobile Club

Unit Information

Type of unit: ATVSnowmobileTrail BikeDune BuggyGolf Cart

Make:

Model:

Year:

Serial/VIN:

Plate/Decal Number:

Engine Displacement (CC):

Use: PleasureBusinessFarm-ranching

Purchase Date:

Purchase Price:

Purchased: NewUsed

Approved Immobilizer: YesNo

Modified Tracks: YesNo

Trailer

Make:

Model:

Year:

VIN:

Lienholder Name:

Lienholder Address/Postal Code:

Additional Information

Third Party Liability: YesNo

Third Party Limits: $200,000$1,000,000$2,000,000

Physical Damage Coverage: YesNo

ALL PERILS/COMPREHENSIVE/SPECIFIED PERILS Value: $

Replacement Cost: YesNo

Search and Rescue: YesNo

Accident Benefits: YesNo

Accident Benefit Limit Options: BASIC $25,000ENHANCED $50,000