Insurance Form | My Website

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1 🚲 Bike & Coverage

Catalogue value (incl. accessories) *

Bike type *

Electric bike?

Brand *

Brand description *

Model *

Frame number *

Key number (ART** lock) *

Policy start date *

Purchase date *

Purchase-value cover *

Track & Trace system

Coverage

Choose at least 1 base coverage: Theft and/or Damage.

Theft Is your bike stolen within the first 3 or 5 years, depending on your cover? Then you are reimbursed the full purchase value; after that a depreciation applies. Your deductible is 5% of the insured amount. For theft of loose parts (such as accessories, battery or lock) the deductible is € 50.

Damage Is your bike damaged, for example by a collision or a fall? Then the damage is reimbursed. Your deductible is € 50.

Breakdown assistance Day and night help from the ANWB emergency centre, throughout the Netherlands and in your home town. Free repair in case of breakdown on the road (parts not included). If the repair cannot be done on the spot, you are brought to your destination or a bicycle repair shop. Up to 3 call-outs per calendar year.

Accidents With the additional Accidents cover, you or your surviving relatives receive a one-off payment after a bicycle accident: death € 5,000; permanent disability up to € 10,000.

Legal aid Are you involved in a traffic accident with your bike? Then you receive legal help with recovering your (injury) damages. Valid in the Netherlands and throughout Europe.

Insurance premium € 0,00 p/m

Are you an ANWB member?

ANWB membership number *

2 👤 Your details

Is this a business application?

Company name *

CoC number *

Salutation *

Initials *

Name prefix

Last name *

Date of birth (min. 16 years) *

E-mail *

Street *

House number *

Addition

Postal code *

City *

Phone

3 💳 Payment & closing questions

Payment method * Monthly payment is only possible by direct debit; with invoice you pay per year.

Payment term *

Account number (IBAN) *

Closing questions

Read the situations below carefully and then indicate whether one or more of them applies to you (or anyone else with an interest in this insurance).

In the past eight years, have you (or anyone with an interest in this insurance) been refused or cancelled insurance, or been offered or continued insurance under different conditions?
In the past eight years, have you (or anyone with an interest in this insurance) been in contact with the police or judiciary as a suspect, or had a criminal measure imposed or carried out, in connection with:
1. for example theft, embezzlement, handling stolen goods, fraud, deception, forgery or attempt(s) thereto;
2. for example destruction, damage, assault, arson, extortion, threat or any crime against personal freedom or life or attempt(s) thereto;
3. illegal possession of drugs or weapons, or violation of the Economic Offences Act.

Does one or more of the above situations apply to you?

Explanation *

In the past 5 years, have you reported a claim on a similar insurance?

Click here to download the insurance card. You can save or print it for later.

I agree to the policy conditions and the insurance card, and to receiving the insurance card digitally. *

BICYCLE INSURANCE

Coverage

Closing questions