Insurance Proposal

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					                   PILLION DECLARATION & WAIVER


DATE:…………………………………………………………………………………………………………

BIKE:………………………………………………………………………….................................................

NAME:………………………………………………………………………………………………………...

ADDRESS:……………………………………………………………………………………………………

TEL EPHONE:………………………………………………………………………………………………..

PASSPORT/ ID #:……………………………………………………………………………………………..

I HAVE READ THE TERMS & CONDITIONS.I UNDERS TAND AND ACCEPT THEM IN
THEIR ENTIRET Y. I HAVE PERSONAL MEDICAL INS URANCE FOR HOME & AB ROAD TO
COVER ME FULL Y IN THE EV ENT OF AN ACCIDENT OR INJ URY.
INS URER / POLICY
DETAILS………………………………………………………………………………

The undersigned voluntarily accepts all risks of personal injury and property damage arising fro m their use
and/or participation in any and all “Wayne’s Wheels” rides, demonstrations, transfers, promotion, shows,
exhibit ions and tours.
The undersigned (or legal pro xy) hereby agrees that he/she and his/her dependants, heirs, executors and
assigns do release and hold harmless the designated rider/s in charg e of the vehicle, as well as Wayne’s
Wheels and their employees, directors, trustees or representatives of Wayne’s Wheels, from any and all
claims, includ ing claims of illness, bodily injury, death or property damage or loss, however caused.

I understand that I am required to wear a helmet by law. I am over 21 years of age (or have obtained legal
permission to partake) I understand and accept that motorcycling carries inherent high risks and I am
prepared to be conveyed as a pillion passenger on an entirely voluntary basis. I agree to abide by decisions
and follow instructions of the designated rider-in-charge.

The undersigned has read and understood this agreement, and will abide by the conditions set by Wayne’s
Wheels, the Terms and Conditions of this and other sections as stated herein or elsewhere published.
The undersigned affirms that he/she has not received or relied on any oral or written representation of
Wayne’s Wheels, as a basis for executing this Release.



SIGNATURE……………………………………….. DATE………………………………………………