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Bicycle Insurance Application


Fraud Warning:  
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.  
 
Consumer Notice of Insurance Scoring:  
In connection with this application for insurance, we may review the unit owner's credit report or obtain or use a credit-based insurance score based on information contained in that report. An insurance score uses information from the credit report to help predict how often you are likely to file claims and how expensive those claims will be. Typical items from a credit report that could affect a score include, but are not limited to, the following: payment history, number of revolving accounts, number of new accounts, the presence of collection accounts, bankruptcies and foreclosures. The information used to develop the insurance score comes from the following consumer reporting agencies: Experian, TransUnion, or Equifax. Future reports may be used to update or renew your insurance.  
 
Auxiliary Power Warning:  
Pedal Cycles with an auxiliary electric power assist source are only eligible for coverage under this program when the rated wattage of the electric power assist motor does not exceed 750 watts or the bicycle manufacturer's published design speed does not exceed 20 miles per hour while under power assist only. Cycles with an auxiliary power source other than electric assist are not eligible for coverage under this program. By continuing, you confirm that your bicycle(s) conform to these requirements.


We do not accept cash or in-person checks. We only process payments by EFT/Electronic Check or Credit Card
Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Marital Status
Required
Do you rent or own your home?
Optional
Do you belong to any following Associations?
Optional


Hold down the Ctrl Key to make multiple selections.
Are you a triathlete?
Optional

Are you a professional cyclist?
Optional

Bicycle #1 YEAR MAKE MODEL
Required
Bicycle #1 Serial No.
Optional
Bicycle #1 TYPE CONSTRUCTION
Required
Bicycle #1 Usage
Optional


Hold down the Ctrl Key to make multiple selections.
Bicycle #1 PURCHASE PRICE DATE NEW OR USED
Optional
Bicycle #1 TOTAL VALUE Bicycle Components Accessories
Required
Bicycle #2 YEAR MAKE MODEL
Optional
Bicycle #2 Serial No.
Optional
Bicycle #2 TYPE and CONSTRUCTION
Optional
Bicycle #2 Usage
Optional


Hold down the Ctrl Key to make multiple selections.
Bicycle #2 PURCHASE PRICE DATE NEW OR USED
Optional
Bicycle #2 TOTAL VALUE Bicycle Components Accessories
Optional
Bicycle #3 YEAR MAKE MODEL
Optional
Bicycle #3 Serial No.
Optional
Bicycle #3 TYPE and CONSTRUCTION
Optional
Bicycle #4 YEAR MAKE MODEL
Optional
Bicycle #4 Serial No.
Optional
Bicycle #4 TYPE and CONSTRUCTION
Optional
Do we have your permission to conduct background information reports (Credit,MVR, CLUE)?
Required
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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