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Agent Information
Agency Name:  
Sub Producer No:    Phone Number: 
Contact Person:   Fax Number:  
Agent Email:
Type of Quote:
Customer Information
First Name: City:  
Last Name State: 
Address Line 1 Zip: 
Address Line 2 Date of Birth:
Applicant has been informed of the Insurance Score Notice  SSN:
Operator Information
Operator #1 Name:    Gender: 
Date of Birth:    Year Began Driving Street Driven Vehicles: 
Marital Status: 
Operator #2 Name:    Gender: 
Date of Birth:    Year Began Driving Street Driven Vehicles: 
Marital Status:  Do you own your own home: 
Unit Information
Location/Garage Zip Code:    Make:    Total Number of Operators: 
Where is unit kept at night?:    Number of Units: 
Model:  CC's:    Year:    Trike?: 
Vin Number:    Trike Manufacturer: 
Eligibility Information
Garaged in city limits?    Is unit street driven?    Valid Motorcycle License? 
Is unit re-titled with a State Assigned Serial Number? 
Own primary residence?    Member of approved Association? 
Total of accessories, sidecars and/or trailers? 
Previous Carrier?    Expiration date of coverage? 
Completed Approved MC driver safety course within 3 years?   
Is applicant not the titled owner?      Is any unit designed/used for racing? 
Any unit salvaged (without a state assigned vin or non-factory built?       
Any unit used for business?     Any unit held for consignment? 
Any unit written in the name of a corporation?      Any unit leased or rented to others?  
In the last 10 years has any non-excluded operator ever been charged with, convicted of, or pleaded no contest to a felony?       
Accidents/Violations within the last 3 years
Number of MINOR violations? Number of MAJOR violations   
Number of AT-FAULT accidents?
Basic Coverages
Bodily Injury Limits:    Property Damage Limits: 
Passenger Liability Limits: 
Uninsured Motorists Bodily Injury:    Underinsured Motorists Bodily Injury: 
Medical Payments:    Limit: 
Comprehensive Deductible:    Collision Deductible: 

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