MOTORCYCLE APPLICATION

Applicant's Name:
Mailing Address:
City    State    Zip
County:

PROPOSED EFFECTIVE DATE:
12:01 A.M. Standard Time at the address of the Applicant
Home Phone:     Work Phone:
Best Time To Call:  
Fax: Email Address:

Current Insurance Company (not agency):     Policy Expiration Date:

Address Where Motorcycle is Garaged (Street):
City: State: Zip:

OPERATOR
Number years with Motorcycle License:   Do you belong to a motorcycle owner’s association? Yes     No
Operator Name:     Date of Birth:      Marital Status
DL# of Operator:     State of DL:
Any tickets or accidents in the past three years? Yes  No    If yes, dates & type of citation:
Current Occupation:
How many yrs experience on motorcycles over 600CC?

COVERAGE
Manufacturer of Motorcycle:   Model of Motorcycle:
Year Model of Motorcycle:       CC’s:
Liability only? Yes     No
What limit of liability? 20/40/15    25/50/15    50/100/50     100/300/100
If full coverage desired, what deductibles on comp and collision?    $250    $500
Do you wish to carry Medical Payments or PIP? Yes     No
What limit of Medical Payments? $1,000     $2,500    $5,000     $10,000
What limit of PIP? $1,000     $2,500    $5,000     $10,000
Use of cycle: Pleasure   To Work or School

Comments:

 

Application Completed By:     Date: