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Michael W. Smith Agency

Revised:

May 06, 2015

Motorcycle

 763-535-7293

 

 

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Motorcycle Insurance Quote Request Form

This is a request for a Minnesota motorcycle quote, not a policy application. Submitting this form does not obligate you to purchase any motorcycle insurance products. Please complete this form as accurately as possible. Motorcycle insurance rates are subject to change.

General Information

Name
Street
City, State ZIP   
E-mail
Phone
FAX

Residence Information

Primary Residence
Months at Address

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Current Motorcycle Insurance Information

Current Company
Expiration Date
Months With Company

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Driver Information (please list all drivers)

Driver #1
Name Birthdate Sex Marital Status Years Experience
Social Security # Drivers License #  

Number of Accidents (Last 5 Years)

Comment on Accidents (Date, Fault, Amount)

Number of Violations (Last 5 Years)

Comment on Violations (Date, Violation Type)

Rider Group Association

If a Rider Safety Course has been completed, please enter date

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Driver #2
Name Birthdate Sex Marital Status Years Experience
Social Security # Drivers License #

Number of Accidents (Last 5 Years)

Comment on Accidents (Date, Fault, Amount)

Number of Violations (Last 5 Years)

Comment on Violations (Date, Violation Type)

Rider Group Association If a Rider Safety Course has been completed, please enter date

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Percentage of Use

  Driver 1. Driver 2.
Motorcycle 1.
Motorcycle 2.

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Motorcycle Information

Motorcycle 1.
Year Make Model Number of CC's
Garaged Anti-theft Alarm Use Years Owned
Yes No Yes No
Describe any special equipment including cost when new & any alterations from manufacturer's specifications

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Motorcycle 2.
Year Make Model Number of CC's
Garaged Anti-theft Alarm Use Years Owned
Yes No Yes No
Describe any special equipment including cost when new & any alterations from manufacturer's specifications

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Coverage's

Liability Coverage. Pays for other people's injuries and damage to their property if you or someone else cause an accident while driving your motorcycle. It protects your assets in the event you are held liable for damage to others.
Bodily Injury Liability Comment
Property Damage Liability

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Medical Expense Coverage. If you and your passengers are injured in an motorcycle accident, this coverage pays your medical expenses.
Medical Expense Comment

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Uninsured and Underinsured Operators Coverage. Pays bodily injury claims if you or your passengers are injured by a negligent uninsured operator, hit-and-run operator or a negligent operator without adequate insurance.
Uninsured/Underinsured Operators
Comment

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Comprehensive Coverage. Pays for damage to your motorcycle caused by theft, fire, windstorm, vandalism and many other non-collision occurrences.

Collision Coverage. If your motorcycle collides with another vehicle or object, this coverage pays to repair your motorcycle.

  Motorcycle 1. Motorcycle 2.
Comprehensive Deductible
Collision Deductible

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Comments

 

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Number of hits since August 15, 1998

 

 

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Copyright 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009 Michael W. Smith Agency