FAST AND EASY CYCLE & ATV INSURANCE PROPOSAL FOR BUSY PEOPLE

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1

FIRST NAMEFirst Name

LAST NAME

Dateof appointment

Addressyour full name

Unit #your full name

Cityyour city

STATE

CA

ZIPZIP

Countyyour county

PHONECELL PHONE#

Emaila valid email

Email again for Accuracya valid email

Homeowner ?

YesNo

Married ?

YesNo

Currently Insured ?

YesNo

Current Insurance Company name ?your full name

DRIVERS SECTION

First Nameyour full name

Last Nameyour full name

Sexpick one!

MaleFemale

Birthdateyour full name

# Years Ridingyour full name

Safety Course ?pick one!

SAFETY COURSEYesNo

Licencse #License #

Yrs Licyour full name

#Ticketsyour full name

# Accidentsyour full name

IF THERE ARE ADDITIONAL DRIVERS PLEASE TYPE HERE ALL THE SAME INFORMATION AS ABOVE FOR EACH DRIVER. (This help text will disappear when you type.)more details

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VEHICLE 1

VEHICLE SECTION

Vehicle Typepick one!

CYCLE TYPEMotorcycleCustomized MotorcycleATVOther Off Road VehicleScooterMoped

Languagepick one!

REGISTRATION ?Off RoadStreet Use

Describe any special equipment or modifications to the Cycle. Type "NONE" if none.your full name

Yearyour full name

MAKE AND MODELyour full name

VEHICLE ID NUMBER (VIN#)your full name

# of CC'syour full name

ANNUAL MILEAGEpick one!

ANNUAL MILES RIDING0 - 5000 MILES A YEAR5000 - 7999 A YEAR8000 - 10,000 A YEAR10,001 - 12,000 A YEAR12,001 - 15,000 A YEAR15,001 - 18,000 A YEAR18,000 OR MORE A YEAR

Value of Bike

Liability Limits

Liability & UM LimitsBasic 25/50/25 25/50Silver 50/100/50 50/100Gold 100/300/100 100/300Platinum 250/500/250 250/500

Comprehensive

Comprehensive DedNo Coverage500 Deductible750 Deductible1000 Deductible1250 Deductible

Collision Deductible

Collision DedNo Coverage500 Deductible750 Deductible1000 Deductible1250 Deductible

Medical ?

YesNo

Tow & Rental?

YesNo

IF THERE ARE ADDITIONAL VEHICLES PLEASE TYPE HERE ALL THE SAME INFORMATION AS ABOVE FOR EACH VEHICLE.more details

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CLICK HERE TO GET YOUR MOTORCYCLE QUOTE

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By clicking the button below you agree to allow our agency to release this information, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. We take your privacy and data security very seriously!

PLEASE LIST ANY SPECIAL COMMENTS ABOUT ANY OF THE ABOVE DRIVERS, VEHICLES, OR COVERAGES.more details

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