Emoto Limited is an agent for PROTECTA Insurance. After submitting this form you will be emailed a "Policy Certificate".

Payment will be required then (not now), but to help us know what data to request, please choose how you will pay:  Monthly by Credit Card Annually by Credit Card Monthly by Direct Debit    

Only advise your Credit Card details to PROTECTA Insurance 0800-435-7868  when you have the Certificate of Insurance and are happy with it. This must be done within 7 days or the policy will be cancelled.

PROTECTA will then send you a full policy document to keep with your "Policy Certificate".

Have you or any proposed rider of the motorcycle:

Been convicted for driving under the influence of drugs or alcohol in the last 5-years? Been convicted for negligent, dangerous or reckless driving in the last 5-years? Had their drivers licence suspended or cancelled for any other reason than above in the last 5-years? Had insurance declined or cancelled or had a claim refused for fraud in the last 5-years? Had any non-traffic criminal convictions in the last 5-years?

Enter Yes or No in the box    

If "Yes", please detail the issue and when it/they occurred. Note, by answering YES we can not guarantee PROTECTA will accept this proposal.

If you answered NO to above, please ignore this box!

Rider details (Please note that if there are regular multiple riders, please email us with the details of the other riders):

Title : Mr. Mrs. Miss Ms. Dr.     Given Name :          Surname :   

Address:

Phone/Mobile/Fax Numbers:

Email:   Date of Birth :   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December          Male   Female   

Percentage this rider uses bike  (if multiple riders):    Confirm what licence class the rider has : Full Motorcycle Restricted Motorcycle Learners Motorcycle Car Licence only Restricted Car Licence only Learner Car Licence only Unlicenced Not Required

Confirm the rider's licence number :    Confirm the version of the rider's licence number :  

Confirm what country the licence is from :   New Zealand Other Country Not Applicable

Confirm the number of motor vehicle or motorcycle accidents the rider has had in the last 5 years :  Select 0 1 2 3 more than 3

Confirm the number of at-fault motor vehicle or motorcycle accidents the rider has had in the last 5 years : Select 0 1 2 more than 2

If you can confirm the claim free years No Claim Bonus for the rider, select the nearest percentage or Grade :  Select Unknown 0% (Grade 4) 20% (Grade 3) 40% (Grade 2) 60% (Grade 1)

Confirm if the rider has owned a motorcycle for more than 12 months in the last 5 years :

Confirm if the rider has current motor insurance, and which insurer :  Select Allianz AAI AMI IAG - NZI/State Lumley Vero Unknown Other Insurer None

Motorcycle Details (If you have more than 1 x bike please email us with the details of the other bikes if they are to go on one policy):    

Make : Select... Adly Aeon American Iron Horse Aprilia Benelli Bimota BMW BSA Buell Bug Cagiva Can-Am CCM CMG Daelim Ducati Forza Gas Gas Gilera Harley Davidson Honda Husaberg Husqvarna Hyosung Italjet Jawa Johnny Pag Kawasaki Keeway KTM Kymco Lifan LML Metrakit Moto Guzzi Moto Morini Motofino MV Agusta Norton Other Peugeot PGO Piaggio Polaris Royal Enfield Sachs Sherco Suzuki SYM TGB Triumph V Moto Vespa Victory Voxan Yamaha    Model :      Category : Adventure ATV Classic Commuter Cruiser Dual Purpose Modern Classic Moped Naked Off Road Power Cruiser Scooter (Metal Body) Scooter (Plastic Body) Sports (Faired) Sports (Unfaired) Sports Tourer Tourer

Engine Capacity :    Year of Manufacture/Registration : 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904   Registration Status : Road Registered Registration Pending Not Required    

Registration No :      VIN Number :

Sum Insured (incl. accessories) $ :   Confirm the value of non-standard accessories if it exceeds $1500 :

Area of Garaging : North Island South Island     Does any party have a financial interest in this motorcycle? :   

If there is, please name of the Finance Company or other party with an interest.

Note: If you require proof of insurance for a Finance Company, this will result in that company being mentioned on the Policy and it can be sent to them to satisfy that requirement.

Policy to commence @ 4:00pm on:  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December