J J Reich Insurance

I HEREBY UNDERSTAND THAT THE INFORMATION PROVIDED HEREIN IS CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT INTENTIONALLY PROVIDING FALSE INFORMATION IS A BREACH OF INSURANCE COVERAGE'S

Coverage Effective Date:

Name of Insured (s)

Email Address

Address:

City:

Province:

Postal:

Phone # (Res):

Phone # (Business):

Email Address

List of Operators:

	Name	Occupation	Drivers Lic#	Date of Birth
Principal
Other (1)
Other (2)

How many claims/violations were made in past 5 years:

List of All Accidents - Claims in past 5 years - Date/Amount/Description (if none state)

List of All vehicle driving violations/convictions/suspensions in past 5 years (if none state)

Number of Years Snowmobile Experience
Number of Years ATV Experience
Has any insurance policy ever been cancelled/declined

If so provide reason

Previous Insurer

Loss, if any to:

Address:

Details of units to be insured:

	Year	Make	Model	Ser#	Type	Appraised Value
(1)
(2)
(3)
(4)
(5)
(6)
Please enter only numbers in the Appraised Value field.
*PREMIUM RATING:*
Deductible:	$1000 $750 $500
1.)
2.)
3.)
4.)
5.)
6.)
Total Premium: $
Premium Surchage: $
(Includes Snoman Safety Program Support) Policy Fee: $
TOTAL SUM ENCLOSED (to nearest dollar): $
(policy rates subject to review by Insurance professional) Minimum Policy Premium $250 for Snowmobiles and $90 for ATVs, plus applicable fees.

Card Type:

Card No.:

Name of Cardholder

Expiry Date:

Policy Premium is minimum and retained (unless insured unit sold)

Name of Sub-Broker (if any):

Address of Sub-Broker:

Date:

Name of Snowmobile Club