MOTORCYCLE INFORMATION SHEET

Please FAX completed form to Dave at (201) 652-0721

 

Name: __________________________________      Today’s Date: ____________________

 

Mailing Address: _____________________________________________________________

 

Telephone Number(s): HOME   ___________ CELL   ____________ WORK ____________

 

Please complete the following on ALL licensed drivers in the household, who will be included for quoting:

Name    Date of Birth    Soc. Sec. #    Driver’s License #  State   M/F     Year Licensed    Marital

                                                                                                            For Motorcycles   Status

 

 

Motorcycle Information:

Motorcycle Year    Make     Model    VIN #      CC’s      Turbo/Supercharged    Annual Mileage  

 

#1 ___________________________________________________________________________

#2 ___________________________________________________________________________

#3 ___________________________________________________________________________

#4 ___________________________________________________________________________

 

Motorcycle Value       Date Purchased         Comprehensive Deductible          Collision Deductible

#1 ___________________________________________________________________________

#2 ___________________________________________________________________________

#3 ___________________________________________________________________________

#4 ___________________________________________________________________________

 

Do you want liability only on the bike?   YES __  NO __

 

Liability Amounts – Please circle one:  15/30   20/40   25/50   50/100   100/300    250/500

 

Does motorcycle value include more than $7,500 in Optional Equipment?  YES __  NO __

 

Is motorcycle kept inside of a locked shed/garage/other?  YES __  NO ___

 

Are any motorcycles used for Business?  __  If so, which motorcycle(s)?   1     2     3     4

 

Do you belong to any motorcycle groups or associations?  YES __  NO __

 

If YES, name of group or association? _______________________________________________

 

Have you received a certificate of completion for taking a motorcycle safety course? YES__NO__

 

Is there a lienholder on the motorcycle?   YES __  NO __

 

Do you presently have Insurance?  YES __  NO __ If NO, date last coverage ended?  _________

 

Prior Insurance Company Name ____________ Reason for Cancellation ___________________

 

How many years have you had continuous insurance? ___________________________________

 

 

How did you hear of our Agency? __________________________________________________

 

WE WILL NEED TO ORDER AN INSURANCE SCORE FOR QUOTING.  PLEASE INITIAL WHERE INDICATED FOR PERMISSION TO ORDER SAID DOCUMENT.

 

X _________