| GENERAL INFORMATION: |
| *Name: |
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| *Address: |
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| *City: |
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| *State: |
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| *Zip Code: |
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| *E-mail address: |
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| *Daytime Phone Number: |
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| *Current Insurance Carrier: |
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| Exp. Date of Current Insurance: |
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DRIVER INFORMATION - Please list ALL persons of driving age in your household below: |
| Driver 1: |
*Name: |
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*Sex: |
Male
Female |
| *Marital Status: |
Single
Married
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| *Date of Birth: |
Mo.
Day
Year
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| *Motorcycle License: |
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| Driver 2: |
Name: |
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Sex: |
Male
Female |
| Marital Status: |
Single
Married |
| Date of Birth: |
Mo.
Day
Year
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| Motorcycle License: |
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| |
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| MOTORCYCLE INFORMATION : |
| CYCLE 1: |
*Make: |
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*Model: |
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| *Year: | |
*CCs: |
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| *VIN: |
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How much coverage is needed
for custom parts & equipment?: |
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*Motorcycle Usage: |
Pleasure
Commute |
*Has the bike been modified
for enhanced performance?: |
Yes
No |
If so, how?: |
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| CYCLE 2: |
Make: |
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Model: |
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| Year: | |
CCs: |
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| VIN: |
|
|
|
How much coverage is needed
for custom parts & equipment?: |
|
Motorcycle Usage: |
Pleasure
Commute |
Has the bike been modified
for enhanced performance?: |
Yes
No |
If so, how?: |
|
| |
|
|
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DRIVING RECORD -
List any and all accidents, claims, or comprehensive losses (glass, at fault, not at fault, hit and run)
in the past 3 years: |
| Driver's Name: |
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Date of Incident: |
Mo.
Year |
| Describe Incident: |
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| Driver's Name: |
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Date of Incident: |
Mo.
Year |
| Describe Incident: |
|
| |
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| Driver's Name: |
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Date of Incident: |
Mo.
Year |
| Describe Incident: |
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| |
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| DRIVING RECORD -
List any and all moving violations or suspensions received in the past 3 years: |
| Driver's Name: |
|
Date of Incident: |
Mo.
Year |
Type of ticket/
reason for suspension
: |
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| Driver's Name: |
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Date of Incident: |
Mo.
Year |
Type of ticket/
reason for suspension
: |
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| Driver's Name: |
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Date of Incident: |
Mo.
Year |
Type of ticket/
reason for suspension
: |
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| COVERAGES -
Please select the coverages you would like on your quote: |
| *Bodily Injury: |
$50,000/100,000
$100,000/300,000
$250,000/500,000 |
| *Property Damage: |
$50,000
$100,000 |
| *Medical Expense: |
$1,000
$2,000
$5,000
$10,000 |
| *Loss of Income: |
Yes
No |
| *Uninsured Motorist Bodily Injury: |
$50,000/100,000
$100,000/300,000
$250,000/500,000 |
*Uninsured Motorist
Property Damage: |
$50,000
$100,000 |
CYCLE 1:
|
|
| Comprehensive Deductible: |
N/A
$100
$250
$500
$1000 |
| Collision Deductible: |
N/A
$100
$250
$500
$1000 |
| Rental
Reimbursement: |
20/$600
30/$900 |
Towing: |
Yes
No |
CYCLE 2:
|
|
| Comprehensive Deductible: |
N/A
$100
$250
$500
$1000 |
| Collision Deductible: |
N/A
$100
$250
$500
$1000 |
| Rental
Reimbursement: |
20/$600
30/$900 |
Towing: |
Yes
No |
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In order to give you the most accurate quote, we will need to run a few reports. The first is a Motor Vehicle Report. The second is a Clue Report which shows prior claims. The third is an Insurance Score, which will contain credit information. In order to run these reports and obtain a quote for you we need your permission. By submitting this request for a quote you are giving us permission to obtain these reports.
Any information which we have or may obtain about you or other individuals listed as policyholders on your policy will be treated confidentially. You have the right to see personal information collected about you and you have the right to correct any information which may be wrong. Upon your request the address of the reporting agency will be supplied so that you can request this information.
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REMEMBER!
Completion of this form constitutes a request for a quotation.
It is not intended to replace or act as an actual insurance contract or binder. |
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