|
Motorcycle
Quote Form |
|
Please
provide the following information as accurate as possible.
Information provided will not be used for anything other than for the
purpose of this form. |
| Name: |
|
| Street
address: |
|
| City: |
|
| State: |
|
| Zip: |
|
| Phone: |
|
| E-Mail: |
|
| Date
of birth: |
|
Have
you had a bankruptcy
tax lien, judgment,
foreclosure, or repossession
in the last three years?: |
|
County
in which the motor-
cycle is principally kept: |
|
Is
the motorcycle garaged
each night?: |
|
Do
you currently have
insurance on your
motorcycle?: |
|
| If
yes, with which company?: |
|
Have
you owned your
present motorcycle for
at least 12 months?: |
|
| Type
of motorcycle: |
|
| Year
Built: |
|
| Make: |
|
| Model: |
|
| CC's: |
|
Is
your motorcycle modified
for enhanced performance?: |
|
Current
value excluding
accessories: |
|
Value
of additional equipment
(Including, but not limited
to: electronic equipment,
antennas, fairings,
windshields, sidecars,
trailers, custom paint,
custom chrome, custom
exhaust, safety riding apparel: |
|
How
do you use your
motorcycle?: |
|
What
limits of liability
coverage do you want?: |
|
Do
you want uninsured/
underinsured motorist
coverage?: |
|
Do
you want passenger
liability coverage for your
passengers?: |
|
Do
you want additional
medical payments for
yourself and your
passengers?: |
|
What
deductible do you
want on comprehensive
coverage?: |
|
What
deductible do you
want on collision coverage?:
|
|
Do
you want roadside
assistance coverage?: |
|
Are
you a member of any
motorcycle association?: |
|
| Driver
#1 info: |
|
| Age: |
|
| Sex: |
|
| Marital
status: |
|
Do
you have the motorcycle
endorsement on your
Florida drivers license?: |
|
Have
you successfully
completed an approved
motorcycle safety course
(MSF) in the last 5 years?: |
|
Do
you have any accidents,
violations, or tickets in the
last three years?: |
|
If
yes, list infractions,
and dates they occurred: |
|
| Driver
#2 info: |
|
| Age: |
|
| Sex: |
|
| Marital
status: |
|
Do
you have the motorcycle
endorsement on your
Florida drivers license?: |
|
Have
you successfully
completed an approved
motorcycle safety course
(MSF) in the last 5 years?: |
|
Do
you have any accidents,
violations, or tickets in the
last three years?: |
|
If
yes, list infractions,
and dates they occurred: |
|
How
did you hear about
Budget Insurance
Offices, Inc.?: |
|
