* Indicates Required Field
Title: * First name: * Last name: *
 
Home Phone #: Work Phone #: Cell Phone #:
 
E-mail address :
 
How should we contact you during business hours?
 
Street address: * How long at this address?
 
City: * State: * Zip Code: *
 
Do you have motorcycle insurance currently? If so, how long without any lapse?
 
 
If so, name of current motorcycle insurance company: Residence status:
 
When do you want this policy to begin? Month⁄Day⁄Year (XX ⁄ XX ⁄ XXXX ) / / *
 
Do you have auto insurance currently? If so, Expiration Date: / /
              Month ⁄ Day ⁄ Year (XX ⁄ XX ⁄ XXXX)
 
If so, name of current auto insurance company:
Do you have homeowners ⁄ condo ⁄ renters insurance currently?
 
If so, Expiration Date  Month⁄Day⁄Year (XX ⁄ XX ⁄ XXXX) / /
 
If so, name of current homeowners ⁄ condo ⁄ renters insurance company:

Cycle Information
Number of Cycles to Insure:
  CYCLE #1 CYCLE #2 CYCLE #3 CYCLE #4
Year *
Make *
Model *
Number of CCs *
Does the Cycle Have
Custom Equipment?
If So, How Much in Dollars? $ $ $ $
Usage
Trike?
Rebuilt Vehicle?
Refitted or Salvaged Vehicle?
Original Frame Replaced?
Want Stated Value?
If So, How Much in Dollars? $ $ $ $
Prior Damage?
Stored in Locked Garage?
Liability Limits:
* 		Selection to left applies to all cycles. Selection to left applies to all cycles. Selection to left applies to all cycles. Selection to left applies to all cycles.
Uninsured Motorist Limits Same as Liability Limits for all cycles. Same as Liability Limits for all cycles. Same as Liability Limits for all cycles. Same as Liability Limits for all cycles.
Comprehensive *
Collision *
Medical Payments
* 		Selection to left applies to all cycles. Selection to left applies to all cycles. Selection to left applies to all cycles. Selection to left applies to all cycles.
Towing⁄Labor (within 100 miles)
Roadside Assistance (>100 miles)
Have Turbo/Nitrous Kit?
Have Altered Frame?
Have Replaced Engine?

Operator Information
Number of Operators to Insure:
  OPERATOR #1 OPERATOR #2 OPERATOR #3 OPERATOR #4
First Name
Middle Name
Last Name		 *
  
*





State Licensed in *
License #
(OPTIONAL)
Gender *
Marital Status *
Relationship Self
Date of Birth
Month ⁄ Day ⁄ Year
  XX   ⁄  XX   ⁄  XXXX 		/ / * / / / / / /
Type of Licence
How Many Years
Have You Had a
US Driver's Licence?
Do You Have a
Motorcycle License?
Ever Convicted of
Insurance Fraud?
License Suspended or
Revoked During Past
3 Years?
Completed Safety
Course?
If So, When?
Month⁄Year
 XX  ⁄  XXXX		 ⁄ ⁄ ⁄ ⁄
AMA Member?
Riding Association
Member?
If So, Which One(s)?
Number of
At-Fault
Accidents in
Past 3 Years
Number of Moving
Violations in Past
3 Years
Comments: