| Yes,
I want to continue |
|
| Policy
Information |
|
New policy
effective date:
(used
only if you decide to purchase a policy) |
// |
| Number of drivers: |
|
| Driver(s) with
only a foreign or international driver's license? |
No
Yes |
| Driver(s) taken
motorcycle safety course in past 3 years? |
No
Yes |
Driver(s) required
by court to carry
SR-22 filing? |
No
Yes |
| Are you a homeowner? |
No
Yes |
| Have you moved
within the last 60 days? |
No
Yes |
| Motorcycle
co-owned by someone living in separate household?(other
than financial institution or leasing company) |
No
Yes |
| ZIP code for
the primary location of your motorcycle: |
|
| Motorcycle
use: |
|
| Model year: |
|
| Make: |
|
Motorcycle Information
We will need some additional
information about your motorcycle. |
|
| Model: |
|
| Engine size
CC's: |
|
| Number of wheels: |
|
| Equipped with
an audible anti-theft device? |
No
Yes |
| Garaged or
chained to a permanent structure? |
No
Yes |
| Motorcycle
modification? |
|
| Value of additional
custom parts and equipment more than $5000?(This
is not the total value of your cycle. Only the additional custom parts
and equipment.) |
No
Yes |
Driver Information
Please review the questions
carefully. |
|
| Driver
Information |
Driver
#1 |
| First name: |
|
| Middle name: |
|
| Last name: |
|
| Name suffix
(i.e., Jr.): |
|
| Home Phone: |
|
| Work Phone: |
|
| Mobile Phone: |
|
| Birth date: |
mm
dd yyyy
// |
| Social Security
Number(optional): |
|
| Gender: |
Male
Female |
| Marital status: |
Single
Married |
| Relationship
to driver #1: |
Insured |
| License status: |
|
| Valid motorcycle
license/endorsement? |
No
Yes |
| Total number
of years experience driving motorcycles: |
|
| Total number
of accidents, comprehensive claims, and traffic violations over the last
3 years: |
|
| Current
Insurance Information |
|
| Recent motorcycle
insurance company : |
|
| Policy expiration
date: |
mm
dd yyyy
// |
| How much do
you currently pay annually for motorcycle insurance?(Optional) |
|
| Current
Address |
|
| Street address: |
|
| City: |
|
| State: |
|
| ZIP code: |
|
Coverage Information
Please select
the coverages you wish to carry. If you have questions regarding a specific
coverage, click on the coverage link for further explanation. |
|
| Policy
Coverage Information |
|
| Liability Coverage
- Bodily Injury & Property Damage, Guest Passenger, Wrongful Death
(BIPD/GP) coverage: |
|
Pedestrian
Personal Injury Protection (PED-PIP) coverage:
(required) |
|
Uninsured Motorists
Bodily Injury (UMBI) coverage:
(required) |
|
Supplemental
Uninsured Motorists Bodily Injury (SUM) coverage:
(may
not exceed Liability Coverage - Bodily Injury & Property Damage, Guest
Passenger, Wrongful Death limit) |
|
| Medical Payments
(MED PAY) coverage: |
|
| Optional Basic
Economic Loss (OBEL) coverage: |
|
| If you make payments on
your vehicle to a bank or finance company, your lender requires physical
damage coverage. |
|
| Vehicle
Coverage Information |
|
| Comprehensive
(COMP) coverage: |
|
Collision (COLL)
coverage:
(requires
Comprehensive coverage) |
|
Roadside Assistance
(RD SIDE) coverage:
(requires
Comprehensive coverage) |
|
Custom Parts
and Equipment:
(requires
Comprehensive coverage) |
|
| Confirm your
e-mail address: |
|
| Note: If your e-mail address
is not listed correctly, please correct it now. |
|
|
|
|
|
