EmailMeForm
Endorsement Request Form - New Brunswick
Please fill in only the information that is required for your change. If something doesn't partain to the change, please leave it blank.
There are 2 areas for uploading all supporting documents needed for the endorsement. All documents you add will be emailed to nbtoys@oasisins.ca once you've clicked submit.
A copy of the request and documents uploaded will also be sent to the broker email address entered.
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Description of change needed
*
Policy Number
*
Endorsement Effective Date MM/DD/YYY
*
Insured Name
*
Brokerage office
*
Brokers Name
*
Broker Phone #
*
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###
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Broker Email
*
Confirm
Insured's Address - Please enter if address has changed
Street Address
City
State / Province / Region
Postal / Zip Code
Please enter unit details here - If adding more than one unit, enter additional units and coverage in remarks at the bottom.
Unit Type
ATV
Snowmobile
Trail Bike - If plated for road use, please specify below.
Dune Buggy
Year
Make
Model
CC's
VIN
Plate Number
Is the Unit New or Used?
Used
New
Will the trail bike be plated for on and off road use?
Yes
No
If the Unit is New, is the 43R endorsement required?
Yes
No
Delivery Date DD/MM/YYYY
Purchase Price
$
Dollars
.
Cents
If new, include unit price, taxes, modifications and freight.
Please select coverage.
Third Party Liability
$500,000
$1,000,000
$2,000,000
Mandatory Coverage with TPL
Accident Benefits
Uninsured Motorist
Health Service Levey
Direct Compensation & Property Damage
SEF 44 - Family Protection (Optional)
Physical Damage
All Perils
Comprehensive
Insured Value
Including any modifications.
Section C Upload
Add File
Please add the Inspection, Bill of Sale, or current insurance if Sec C is required.
Deductible
$500- Mandatory
$1000 - Optional
$2500- Optional
$5000- Optional
Endorsements
Business Use
Rider Plus
43R - Limited Waiver of Depreciation
Modifications - Include value of modifications
Optional - Truck Deck or Trailer - Include Value
Lien Holder (if applicable) include name, address, city, prov and postal code.
Principle Operator
Name of Principle Operator
Date of Birth DD/MM/YYYY
Drivers Licence #
Years Riding Experience
# of convictions in the last 3 years
# of claims in the last 3 years
Occupation
Safety Course - AQCC/CASI or Canadian Safetly Counsel?
ATV
Sled
Trail Bike
Avalanche Course
Is the Insured a member of;
NBATVF - ATV's only
NBSF - SM only
Additional Information - Please fill out all the information that applies to your change request.
Turbos, after market enhancements or added equipment designed to modify or enhance the performance?
After Market Performace Enhancement Equipment
Turbo
Added Equipment (Tracks)
Other - add in remarks
Unit #
If the unit is a Trail Bike, will it have tracks?
Yes
No
If tracks will be added at anytime during the policy please check yes even if they aren't currently on.
Unit #
Safety Immobilizer or Spot Trace tracking device?
Yes
No
Unit #
Business Use - if applicable
Is there business use on any units?
Yes
No
If there is buiness use on any of the units please fill out the information below.
Unit(s) #
% of Business
% of Pleasure
How many KM driven anually?
Please describe the nature of the business
Remarks
File Upload
Add File
Please upload all supporting documents, these documents will be automatically emailed with your request to Oasis once submitted.
