Motorcycle Insurance Questionnaire
Applicant's Information
1st Drivers Name
SSN
Address
City
State
Zip
Home Phone
Work Phone
Drivers License #
State Issued
Sex
Male
Female
Birthdate
Occupation
Years Experience on Motorcycles
Motorcycle Club Name
Motorcycle Safety Course
Yes
No
2nd Drivers Name
SSN
Drivers License #
State Issued
Sex
Male
Female
Birthdate
Years Experience on Motorcycles
Motorcycle Club Name
Motorcycle Safety Course
Yes
No
Vehicle Information
VIN #
Year
Model
CCs
Miles Driven One Way
Accessories & Add-On Equipment: (Any equipment not factory standard on basic cycle must be listed for coverage) Submit copies of invoice if actual cash value of accessories exceeds $2000. If value exceeds $5,000, also include a photograph.
Previous Loss Information
Previous Losses (include auto losses)
Yes
No
If yes, provide the following:
Date of Loss
Amount Paid ($)
At Fault?
Yes
No
Date of Loss
Amount Paid ($)
At Fault?
Yes
No
Date of Loss
Amount Paid ($)
At Fault?
Yes
No
Any violations in the past 5 years? (including auto)
Yes
No
If yes, provide the following:
Date
Name
Current Insurance Coverage
Liability ($)
Personal Injury Protection ($)
Uninsured Motorist ($)
Underinsured Motorist ($)
Towing & Labor ($)
Rental Reimbursement ($)
Comp Deductible ($)
Collision Deductible ($)