Insurance Score / Claim History Disclosure

In connection with this application for insurance, we may review your credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of your insurance score. In connection with this application for insurance, we may review your claims history or loss experience and may report future claims made by you to a claims history provider.

Applicant agrees to these terms. *    

Motorcycle/ATV/Golf Cart Quote Form

Please complete and submit this form or call us at 1-800-632-1343 for your quote.

You can have up to four drivers and four machines on your policy.
However, this form only allows you to provide information for one driver and one machine.
If you have multiple machines and/or drivers, just call us!

All fields marked with an asterisk are required. For some of the coverage-specific questions
below, you may find it useful to have your current policy or declarations page handy.


First Name: *    
Last Name: *    
Date of Birth (mm/dd/yyyy): *    
Address: *    
City: *    
State/Province: *    
Zip Code: *    
If the motorcycle/ATV/golfcart is garaged in another state,
please provide that state here:    
What date do you want your coverage to take
effect (mm/dd/yyyy)? *    

Additional Applicant Information
How many years have you operated street
cycles (not ATVs or dirt bikes)?    
Do you currently have a valid motorcycle license? *    
Yes       No      
Have you completed a motorcycle driver's education
course in the last three years? *    
Yes       No      
Do you own your own home? If so, you may qualify
for a discount.    
Yes       No      
Are you a member of a motorcycle club or organization?
If so, you may qualify for a discount.    
Yes       No      
If so, please provide the name of the club:    

Cycle Information
Current market value: *    
Model Year: *    
VIN number:    
Make: *    
Model: *    
Manufacturer: *    
Engine size (cc's): *    
Is the cycle/unit currently insured? *    
Yes       No      
If yes, who is your current insurance company?    
Is the cycle a trike?    
Yes       No      
Is the cycle a street driven unit?    
Yes       No      
Is the motorcycle/ATV/golfcart kept in a secure location (i.e. locked garage)
at night? *    
Yes       No      

Accident/Violation Information
Thinking about the past three years of your driving record, please indicate the number of each type of violation that
you have. Note that we do verify this information when a policy is purchased.
Number of minor violations: *    
Number of major violations: *    
Number of at-fault violations: *    

Coverages and Limits
You may find it helpful to have your current policy in front of you when filling out this information.
Amount of Bodily Injury coverage: *    
Amount of medical payments coverage: *    
Amount of property damage coverage: *    
Amount of uninsured/underinsured motorist bodily injury coverage: *    

Please provide the following information so we can contact you with your quote.
We respect your privacy and will never sell or rent your contact information to third parties.
How would you prefer that we contact you? *    
Daytime Phone       Alternate Phone       E-mail      
Daytime Phone Number:    
Alternate Phone Number:    
Email:    
Best Time to Contact    
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