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Welcome to our motorcycle insurance questionaire. Please just take a few minutes out of your time to answer these questions and you will be on your way to low motorcycle insurance rates! Please make sure all information is both current and accurate. Just submit your information at the end of this questionnaire and one of our representatives will get back to you as soon as possible with a quote.
Thank You.
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First, let's find out more about you.
Contact Information |
| Prefix: |
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| First Name: |
M.
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| Last Name: |
Sfx:
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| I prefer to be contacted by: |
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| E-mail: |
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| Date of Birth: |
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| Sex: |
Male
Female |
| Marital Status: |
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| Social Security Number: |
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| Drivers License Number: |
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| Address: |
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| City: |
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| State: |
Zip:
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| How long have you lived at residence? |
yrs.
mns.
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| If less than six months, please provide prior address. |
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| Daytime phone: |
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| Evening phone: |
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| Is your spouse an operator? |
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Now, we just need some information on your motorcycle.
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| Do you have Motorcycle Insurance now? |
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| How many motorcycles would be on the policy? |
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| What zip code is your vehicle parked in overnight? |
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| What is the Year of the motorcycle? |
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| What is the Make of the motorcycle? |
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| What is the Model of the motorcycle? |
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| What is the CC size of the motorcycle? |
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| What is the primary use of the motorcycle? |
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| Does your motorcycle have an audible alarm on it? |
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| How many tickets, excluding parking tickets, have you had in the past five years? |
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Ticket or Accident One
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| Please enter the ticket or accident date |
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| In which state did it take place? |
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Violations, injuries?
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| If you received a ticket, which violation best describes the ticket? |
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| Did anyone get injured? |
Yes
No
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Details
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| Decscribe your accident: |
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| Description of Accident: |
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Ticket or Accident Two
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| Please enter the ticket or accident date |
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| In which state did it take place? |
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Violations, injuries?
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| If you received a ticket, which violation best describes the ticket? |
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| Did anyone get injured? |
Yes
No
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Details
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| Decscribe your accident: |
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| Description of Accident: |
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Ticket or Accident Three
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| Please enter the ticket or accident date |
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| In which state did it take place? |
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Violations, injuries?
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| If you received a ticket, which violation best describes the ticket? |
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| Did anyone get injured? |
Yes
No
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Details
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| Decscribe your accident: |
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| Description of Accident: |
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Ticket or Accident Four
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| Please enter the ticket or accident date |
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| In which state did it take place? |
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Violations, injuries?
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| If you received a ticket, which violation best describes the ticket? |
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| Did anyone get injured? |
Yes
No
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Details
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| Decscribe your accident: |
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| Description of Accident: |
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Convictions, suspensions, tickets
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| Has your license been suspended in the last five years? |
Yes
No
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| Has your license been revoked in the last five years? |
Yes
No
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| Have you ever been convicted of a DUI in the last five years? |
Yes
No
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| Have you ever been convicted of a DWI in the last five years? |
Yes
No
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| Do you currently have a valid motorcycle drivers license? |
Yes
No
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| If not, do you have a motorcycle permit? |
Yes
No
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| How many years of motorcycle experience do you have? |
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| Have you taken a motorcycle safety course? |
Yes
No
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| When? |
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| What kind of coverages are you looking for? |
Minimum basic liability-25/50/10
General Liability-50/100/25
Preferred Liability-100/300/50
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| Do you want comprehensive and collision coverage? |
Yes
No
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| If so, what deductible would you want? |
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| To continue to the next section, please hit the submit button |
 
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