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Motorcycle  Quote
This information is optional, however
providing your SS# will produce the most
accurate quote.
Marital Status
Single
Married
Do you have a valid Texas Driver's License?
Do you have a motorcycle endorsement?
Have you successfully completed a ATV
safety course in the past 36 months?
_______________________________________________________________________
Garaging Address (If different from above)
_______________________________________________________________________
Driving History
Number of ( At Fault) Accidents in the past 36 months
Number of ( Not At Fault) Accidents in the past 36 months
Number of Tickets in the past 36 months
Number of years Motorcycle experience
_______________________________________________________________________
Motorcycle Details
Motorcycle #1
Motorcycle #2
Trailer
Is vehicle kept in an enclosed, locked structure?
Is there a Lienholder ?
Have you had insurance on this type of vehicle in the past 6 months?
Do you have insurance on this vehicle now?
_______________________________________________________________________
Coverage Details
What are the coverages you would like quoted to you?
Liability Only
Liability and Comprehensive (Includes Theft)
Liability and Comprehensive + Collision
Optional Coverages you may want quoted to you
Uninsured Motorist
Medical Payments
PIP (Personal Injury Protection)
How would you like us to respond to this quote request?
E-mail
Phone
 Both
B.P. Cummings

                  Insurance Agency

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