Motorcycle/ATV/Scooter Insurance Request Form

Current Insurance Information
Insurance Company:     Expiration date:

Coverage Information....

LIABILITY Bodily Injury per Person / Bodily Injury per Accident / Property Damage per accident

Un & Underinsured Motorist Coverage

$15,000 per person/$30,000 per accident/$10,000 Property Damage $25,000 per person/$50,000 per accident/$10,000 Property Damage $25,000 per person/$50,000 per accident/$15,000 Property Damage $25,000 per person/$50,000 per accident/$25,000 Property Damage $50,000 per person/$100,000 per accident/$15,000 Property damage $50,000 per person/$100,000 per accident/$25,000 Property damage $100,000 per person/$300,000 per accident/$25,000 Property damage $100,000 per person/$300,000 per accident/$50,000 Property damage $250,000 per person/$500,000 per accident/$100,000 Property damage $300,000 per Accident $500,000 per Accident

Rejected $ 15,000 per person/$ 30,000 per accident $ 25,000 per person/$ 50,000 per accident $ 50,000 per person/$ 100,000 per accident $ 100,000 per person/$ 300,000 per accident

Vehicle Information
These vehicle(s) are:  Motorcycle Custom Motorcycle Dirt Bike Dune Buggy Golf Cart All Terrain Vehicle Motor Scooter     How long have you owned it?  Years
  s

1	YEAR	MAKE & MODEL	CCs	Current Value	COMPREHENSIVE DED	COLLISION DED	ACCESSORIES
		VIN:  Financed:Yes / No		$	1002505001,000	1002002505001,000	$
			Anti-Theft Device? Yes / No			Anti-Lock Brakes? Yes / No
2	YEAR	MAKE & MODEL	CCs	Current Value	COMPREHENSIVE DED	COLLISION DED	ACCESSORIES
		VIN:  Financed:Yes / No		$	1002002505001,000	1002002505001,000	$
			Anti-Theft Device? Yes / No			Anti-Lock Brakes? Yes / No
3	YEAR	MAKE & MODEL	CCs	Current Value	COMPREHENSIVE DED	COLLISION DED	ACCESSORIES
		VIN:  Financed:Yes / No		$	1002002505001,000	1002002505001,000	$
			Anti-Theft Device? Yes / No			Anti-Lock Brakes? Yes / No
4	YEAR	MAKE & MODEL VIN Number	CCs	Current Value	COMPREHENSIVE DED	COLLISION DED	ACCESSORIES
		VIN:  Financed:Yes / No		$	1002002505001,000	1002002505001,000	$
			Anti-Theft Device? Yes / No			Anti-Lock Brakes? Yes / No

Driver Information

Driver Name 1	Birth	License #	Social Security # (Optional)	Sex	Marital Status	(Years) Motorcycle Experience	Motorcycle License
				MaleFemale	MarriedSingle		Yes / NO
Motorcycle Safety Course (last 3 years): Yes / No (Certificate Required) / Date of Course:					Association Membership: A Brotherhood Aiming Toward EducationAmerican Motorcycle AssociationBMW Motorcycle Owners of AmericaBuell Riders Adventure GroupChristian Motorcyclists AssociationGold WIng Road Riders AssociationGold Wing Touring AssociationHarley Owners GroupHonda Riders Club of AmericaIndian Riders GroupMotorcycle Safety FoundationMoto Guzzi National Owners ClubRiders Association of TriumphRSTAR Touring & Riding AssociationRetreadsUnited Sidecar AssociationVenture Touring SocietyWomen on Wheels
Driver Name 2	Birth	License #	Social Security # (Optional)	Sex	Marital Status	(Years) Motorcycle Experience	Motorcycle License
				MaleFemale	MarriedSingle		Yes / NO
Motorcycle Safety Course (last 3 years): Yes / No (Certificate Required) / Date of Course:					Association Membership: A Brotherhood Aiming Toward EducationAmerican Motorcycle AssociationBMW Motorcycle Owners of AmericaBuell Riders Adventure GroupChristian Motorcyclists AssociationGold WIng Road Riders AssociationGold Wing Touring AssociationHarley Owners GroupHonda Riders Club of AmericaIndian Riders GroupMotorcycle Safety FoundationMoto Guzzi National Owners ClubRiders Association of TriumphRSTAR Touring & Riding AssociationRetreadsUnited Sidecar AssociationVenture Touring SocietyWomen on Wheels
Driver Name 3	Birth	License #	Social Security # (Optional)	Sex	Marital Status	(Years) Motorcycle Experience	Motorcycle License
				MaleFemale	MarriedSingle		Yes / NO
Motorcycle Safety Course (last 3 years): Yes / No (Certificate Required) / Date of Course:					Association Membership: A Brotherhood Aiming Toward EducationAmerican Motorcycle AssociationBMW Motorcycle Owners of AmericaBuell Riders Adventure GroupChristian Motorcyclists AssociationGold WIng Road Riders AssociationGold Wing Touring AssociationHarley Owners GroupHonda Riders Club of AmericaIndian Riders GroupMotorcycle Safety FoundationMoto Guzzi National Owners ClubRiders Association of TriumphRSTAR Touring & Riding AssociationRetreadsUnited Sidecar AssociationVenture Touring SocietyWomen on Wheels
Driver Name 4	Birth	License #	Social Security # (Optional)	Sex	Marital Status	(Years) Motorcycle Experience	Motorcycle License
				MaleFemale	MarriedSingle		Yes / NO
Motorcycle Safety Course (last 3 years): Yes / No (Certificate Required) / Date of Course:					Association Membership: A Brotherhood Aiming Toward EducationAmerican Motorcycle AssociationBMW Motorcycle Owners of AmericaBuell Riders Adventure GroupChristian Motorcyclists AssociationGold WIng Road Riders AssociationGold Wing Touring AssociationHarley Owners GroupHonda Riders Club of AmericaIndian Riders GroupMotorcycle Safety FoundationMoto Guzzi National Owners ClubRiders Association of TriumphRSTAR Touring & Riding AssociationRetreadsUnited Sidecar AssociationVenture Touring SocietyWomen on Wheels
Driver Name 5	Birth	License #	Social Security # (Optional)	Sex	Marital Status	(Years) Motorcycle Experience	Motorcycle License
				option>MaleFemale	MarriedSingle		Yes / NO
Motorcycle Safety Course (last 3 years): Yes / No (Certificate Required) / Date of Course:					Association Membership: A Brotherhood Aiming Toward EducationAmerican Motorcycle AssociationBMW Motorcycle Owners of AmericaBuell Riders Adventure GroupChristian Motorcyclists AssociationGold WIng Road Riders AssociationGold Wing Touring AssociationHarley Owners GroupHonda Riders Club of AmericaIndian Riders GroupMotorcycle Safety FoundationMoto Guzzi National Owners ClubRiders Association of TriumphRSTAR Touring & Riding AssociationRetreadsUnited Sidecar AssociationVenture Touring SocietyWomen on Wheels

Accidents and Violations
Do you have any accidents or violations in the last 3 years?   Yes    No

If YES, Please List......

	DATE	DRIVER	TYPE OF OCCURRENCE
1			NONEAccident: At Fault: Less than $1,050Accident: At Fault: More than $1,049Accident: Not At-faultA.R.D. EnrollmentCareless DrivingComprehensive Claim: Not Glass Breakage under $1,000Comprehensive Claim: Not Glass Breakage over $1,000Comprehensive Claim: Glass Breakage OnlyDisplaying Foreign License During SuspensionDrag RacingDriving with a Suspended/Revoked LicenseDriving Left of CenterDriving on Left Side of HighwayDriving Too Fast For ConditionsDriving Without Lights to Avoid ArrestDriving Without a LicenseDUI or DWIEluding an OfficerFailure to Give Information, and Render AidFailure to Submit to Alcohol/Drug TestFailure to YieldFelony with a VehicleFelony theft of vehicleFiling due to point totalFiling due to ViolationFleeing from policeFollowing too closelyHit & Run involving death or injuryHit & Run involving attended vehicleHomicide with a vehicleIllegal/Improper PassingImproper BackingImproper PassingImproper TurnLeaving the Accident: Property Damage OnlyLeaving the Accident: Bodily InjuryNon-Vehicle FelonyOpen BottleOperate without consentOperating Vehicle After Registration SuspendedPassing a School BusPermitting use of an Unauthorized VehiclePermitting an Unauthorized Person to DriveRacing on Highways including drag racingReckless DrivingRevoked License due to ViolationSpeeding: under 15 mph over limitSpeeding: 15 mph or over limitSpeeding: with InjuryStop sign/traffic lightSuspended License due to ViolationTrespass by Motor VehicleWrong WayAll Other Not Listed
2			Accident: At Fault: Less than $1,050Accident: At Fault: More than $1,049Accident: Not At-faultA.R.D. EnrollmentCareless DrivingComprehensive Claim: Not Glass Breakage under $1,000Comprehensive Claim: Not Glass Breakage over $1,000Comprehensive Claim: Glass Breakage OnlyDisplaying Foreign License During SuspensionDrag RacingDriving with a Suspended/Revoked LicenseDriving Left of CenterDriving on Left Side of HighwayDriving Too Fast For ConditionsDriving Without Lights to Avoid ArrestDriving Without a LicenseDUI or DWIEluding an OfficerFailure to Give Information, and Render AidFailure to Submit to Alcohol/Drug TestFailure to YieldFelony with a VehicleFelony theft of vehicleFiling due to point totalFiling due to ViolationFleeing from policeFollowing too closelyHit & Run involving death or injuryHit & Run involving attended vehicleHomicide with a vehicleIllegal/Improper PassingImproper BackingImproper PassingImproper TurnLeaving the Accident: Property Damage OnlyLeaving the Accident: Bodily InjuryNon-Vehicle FelonyOpen BottleOperate without consentOperating Vehicle After Registration SuspendedPassing a School BusPermitting use of an Unauthorized VehiclePermitting an Unauthorized Person to DriveRacing on Highways including drag racingReckless DrivingRevoked License due to ViolationSpeeding: under 15 mph over limitSpeeding: 15 mph or over limitSpeeding: with InjuryStop sign/traffic lightSuspended License due to ViolationTrespass by Motor VehicleWrong WayAll Other Not Listed
3			Accident: At Fault: Less than $1,050Accident: At Fault: More than $1,049Accident: Not At-faultA.R.D. EnrollmentCareless DrivingComprehensive Claim: Not Glass Breakage under $1,000Comprehensive Claim: Not Glass Breakage over $1,000Comprehensive Claim: Glass Breakage OnlyDisplaying Foreign License During SuspensionDrag RacingDriving with a Suspended/Revoked LicenseDriving Left of CenterDriving on Left Side of HighwayDriving Too Fast For ConditionsDriving Without Lights to Avoid ArrestDriving Without a LicenseDUI or DWIEluding an OfficerFailure to Give Information, and Render AidFailure to Submit to Alcohol/Drug TestFailure to YieldFelony with a VehicleFelony theft of vehicleFiling due to point totalFiling due to ViolationFleeing from policeFollowing too closelyHit & Run involving death or injuryHit & Run involving attended vehicleHomicide with a vehicleIllegal/Improper PassingImproper BackingImproper PassingImproper TurnLeaving the Accident: Property Damage OnlyLeaving the Accident: Bodily InjuryNon-Vehicle FelonyOpen BottleOperate without consentOperating Vehicle After Registration SuspendedPassing a School BusPermitting use of an Unauthorized VehiclePermitting an Unauthorized Person to DriveRacing on Highways including drag racingReckless DrivingRevoked License due to ViolationSpeeding: under 15 mph over limitSpeeding: 15 mph or over limitSpeeding: with InjuryStop sign/traffic lightSuspended License due to ViolationTrespass by Motor VehicleWrong WayAll Other Not Listed
4			Accident: At Fault: Less than $1,050Accident: At Fault: More than $1,049Accident: Not At-faultA.R.D. EnrollmentCareless DrivingComprehensive Claim: Not Glass Breakage under $1,000Comprehensive Claim: Not Glass Breakage over $1,000Comprehensive Claim: Glass Breakage OnlyDisplaying Foreign License During SuspensionDrag RacingDriving with a Suspended/Revoked LicenseDriving Left of CenterDriving on Left Side of HighwayDriving Too Fast For ConditionsDriving Without Lights to Avoid ArrestDriving Without a LicenseDUI or DWIEluding an OfficerFailure to Give Information, and Render AidFailure to Submit to Alcohol/Drug TestFailure to YieldFelony with a VehicleFelony theft of vehicleFiling due to point totalFiling due to ViolationFleeing from policeFollowing too closelyHit & Run involving death or injuryHit & Run involving attended vehicleHomicide with a vehicleIllegal/Improper PassingImproper BackingImproper PassingImproper TurnLeaving the Accident: Property Damage OnlyLeaving the Accident: Bodily InjuryNon-Vehicle FelonyOpen BottleOperate without consentOperating Vehicle After Registration SuspendedPassing a School BusPermitting use of an Unauthorized VehiclePermitting an Unauthorized Person to DriveRacing on Highways including drag racingReckless DrivingRevoked License due to ViolationSpeeding: under 15 mph over limitSpeeding: 15 mph or over limitSpeeding: with InjuryStop sign/traffic lightSuspended License due to ViolationTrespass by Motor VehicleWrong WayAll Other Not Listed