PERSONAL OFF-ROAD QUOTE         

PERSONAL INFORMATION

        First Name                                  
        Last Name                                   
        Garaging Address                      
        Garaging City                              
        Garaging Zip Code                     
        Phone Number                            
        Fax Number                                
        E-Mail Address                           
        Who Referred You to Our Site? 
 

MAILING ADDRESS (OPTIONAL)

        Mailing Address (If Different from Garaging)   
        Mailing City                                 
        Mailing State                              
        Mailing Zip Code                        
 

DRIVER INFORMATION

Driver 1             

        First Name                
        Birthdate                    
- Male Female                                                        Sex                                          
- single married divorced widowed separated                                                    Marital Status
        Yrs Licensed  
        State Licensed
        Occupation

        Years experience

Violations - Minors (last 3 years) / Majors (last 7-10 years)

- None 1 2 3 4                                                             Minor Violations - Speeding, Failure to Stop, etc.

- None 1 2 3 4                                                             Accidents - Non Chargeable

- None 1 2 3 4                                                             Accidents - Chargeable

- None 1 2 3 4                                                             Major Violations - Drunk Driving, Reckless, Hit & Run, etc.

Driver 2             

        First Name                
        Birthdate                    
- Male Female                                                        Sex                                          
- single married divorced widowed separated                                                    Marital Status
        Yrs Licensed  
        State Licensed
        Occupation

        Relation to Insured

        Years experience

Violations - Minors (last 3 years) / Majors (last 7-10 years)

- None 1 2 3 4                                                             Minor Violations - Speeding, Failure to Stop, etc.

- None 1 2 3 4                                                             Accidents - Non Chargeable

- None 1 2 3 4                                                             Accidents - Chargeable

- None 1 2 3 4                                                             Major Violations - Drunk Driving, Reckless, Hit & Run, etc.

Driver 3             

        First Name                
        Birthdate                    
- Male Female                                                        Sex                                          
- single married divorced widowed separated                                                    Marital Status
        Yrs Licensed  
        State Licensed
        Occupation

        Relation to Insured

        Years experience

Violations - Minors (last 3 years) / Majors (last 7-10 years)

- None 1 2 3 4                                                             Minor Violations - Speeding, Failure to Stop, etc.

- None 1 2 3 4                                                             Accidents - Non Chargeable

- None 1 2 3 4                                                             Accidents - Chargeable

- None 1 2 3 4                                                             Major Violations - Drunk Driving, Reckless, Hit & Run, etc.

Driver 4             

        First Name                
        Birthdate                    
- Male Female                                                        Sex                                          
- single married divorced widowed separated                                                    Marital Status
        Yrs Licensed  
        State Licensed
        Occupation

        Relation to Insured

        Years experience

Violations - Minors (last 3 years) / Majors (last 7-10 years)

- None 1 2 3 4                                                             Minor Violations - Speeding, Failure to Stop, etc.

- None 1 2 3 4                                                             Accidents - Non Chargeable

- None 1 2 3 4                                                             Accidents - Chargeable

- None 1 2 3 4                                                             Major Violations - Drunk Driving, Reckless, Hit & Run, etc.

OFF-ROAD VEHICLE INFORMATION

Off-Road Vehicle 1    

        Year                       
        Make                     
        Model                   
        I.D. #                      
- Pleasure To/From Work/School Business                                   Vehicle Usage
        Miles driven one-way from home to work or school
- 0-3,000 3,001-5,000 5,001-8,000 8,001-10,000 10,001-12,000 12,001-15,000 15,000 +                                                 Annual Miles

        Value

        CC Size

- ATV Dirt Bike Dune Buggy                                                   Type

        Number of Wheels

Off-Road Vehicle 2   

        Year                       
        Make                     
        Model                   
        I.D. #                      
- Pleasure To/From Work/School Business                                   Vehicle Usage
        Miles driven one-way from home to work or school
- 0-3,000 3,001-5,000 5,001-8,000 8,001-10,000 10,001-12,000 12,001-15,000 15,000 +                                                 Annual Miles

        Value

        CC Size

- ATV Dirt Bike Dune Buggy                                                   Type

        Number of Wheels

COVERAGE INFORMATION

- 15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000 500,000/500,000 300,000 CSL 500,000 CSL                                              Bodily Injury               
- 10,000 25,000 50,000 100,000 250,000 500,000                                                          Property Damage                        
- No Coverage 15,000/30,000                                                 Uninsured Motorist

- No Coverage 3,500 Coll. Deductible Waiver                                  Uninsured Motorist Property Damage or CDW
- No Coverage 1,000 2,000 3,000 4,000 5,000                                                 Medical Payment              

- Yes No                                                                Do you need limits to satisfy an umbrella policy? 

DEDUCTIBLE INFORMATION

Off-Road Vehicle 1     

- None 50 100 250 500 1000                                                             Comprehensive             

- None 50 100 250 500 1000                                                             Collision      

- Yes No                                                                Towing  

Off-Road Vehicle 2     

- None 50 100 250 500 1000                                                             Comprehensive             

- None 50 100 250 500 1000                                                             Collision      

- Yes No                                                                Towing    

UNDERWRITING INFORMATION

- Yes No                                Is the off-road vehicle garaged in a fully locked structure?   

- Yes No                                Has any operator completed an off-road safety course in the last 3 years?   

- Yes No                                Are any of the off-road vehicles turbocharged or supercharged?

- Yes No                                Is the off-road vehicle licensed for street/road use?   

- Yes No                                Has the off-road vehicle been altered or customized in any way? 

      If so, what has been done?   

MISCELLANEOUS INFORMATION

        Current Insurance Company   
        Expiration Date:                          
        Current Premium                        

Questions or Comments to help the Agent:

               

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