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Driver Information:

Primary Driver

Safety Course
(either Safety Foundation Course or Safety Foundation Instructor:
Organizations (either AMA, HOG, or Other):
Class M License? Yes No  
Do you own or rent your home? Own Rent
Years of driving experience:  
Years Motorcycle Driving Experience:  
Zip Code Where Motorcycle Is Garaged?  
Who referred you to our website?
Any accidents or violoations: (be specific)

Motorcycle Information:

Date Purchased:
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  
Please indicate type: (Cruiser, Touring, Standard, Off Road, ATV, Super, Sport 1 or 2, etc.)
Accessories in excess of $5,000? Yes No  
Value of bike when new ($):  
Motor vehicle accidents or violoations: (be specific)
Insurance coverage desired: Full Coverage Liability Only
Coverage Amounts Desired:
  Bodily Injury Property Damage
Personal liability
Uninsured motorist
Personal injury protection  
Current insurance company:
Current premium amount:
Comments or Questions:



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