Motorcycle Information: |
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| Date Purchased: |
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| Is the unit kept in a fully enclosed /locked structure? |
Yes
No |
| Is the unit Turbo Charged? |
Yes
No |
| Have you installed a Low Jack on the vehicle? |
Yes
No |
| Trailer coverage desired: |
Yes
No |
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| Please indicate type: (Cruiser, Touring, Standard, Off Road, ATV, Super, Sport 1 or 2, etc.) |
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| Accessories in excess of $5,000? |
Yes
No |
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| Value of bike when new ($): |
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| Motor vehicle accidents or violoations: (be specific) |
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| Insurance coverage desired: |
Full Coverage
Liability Only |
| Coverage Amounts Desired: |
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Bodily Injury |
Property Damage |
| Personal liability |
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| Uninsured motorist |
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| Personal injury protection |
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| Current insurance company: |
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| Current premium amount: |
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| Comments or Questions: |
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