PERSONAL MOTORCYCLE 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 Motorcycle experience

- Yes No                                                               Motorcycle endorsement on license?

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 Motorcycle experience

- Yes No                                                               Motorcycle endorsement on license?

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 Motorcycle experience

- Yes No                                                               Motorcycle endorsement on license?

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 Motorcycle experience

- Yes No                                                               Motorcycle endorsement on license?

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.

MOTORCYCLE INFORMATION

Motorcycle 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

Motorcycle 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

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 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                                              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

Motorcycle 1     

- None 50 100 250 500 1000                                                             Comprehensive             

- None 50 100 250 500 1000                                                             Collision      

- Yes No                                                                Towing  

Motorcycle 2     

- None 50 100 250 500 1000                                                             Comprehensive             

- None 50 100 250 500 1000                                                             Collision      

- Yes No                                                                Towing    

UNDERWRITING INFORMATION

- Yes No                              Is the motorcycle garaged in a fully locked structure?   

- Yes No                              Does any operator belong to an approved motorcycle organization?

     If so, which organization?   

- Yes No                              Has any operator completed a motorcycle safety course in the last 3 years?   

- Yes No                              Are any of the motorcycles turbocharged or supercharged?   

- Yes No                              Has the motorcycle 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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