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Driver #1 Information

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Driver’s license number

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Number of years licensed

Date of motorcycle license (if any)

List all citations received in the past 3 years
(Please include non-moving violation, type of violation, approximate date of violation).

List any suspensions of your license in the last 3 years. (Even if only for one day).

List any DUI ever received and approximate date of violation

List all accidents that were your fault

List all accidents that were NOT your fault

List any other registered owners

Motorcycle #1 Information

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Make

Model

Vehicle ID Number

Body Style

Engine CC’s

List any club memberships
Goldwing, etc.

Date of any motorcycle safety course taken (if any)

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 Liability

Liability Limits

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 Un(der)insured Motorist-Will Match Liability Selection

 Medical/Personal Injury Protection

 Comprehensive

Comprehensive Deductible

Select Comprehensive Coverage N/A $100 Deductible $250 Deductible $500 Deductible $1000 Deductible

 Collision

Collision Deductible

Select Collision Coverage N/A $50 Deductible $100 Deductible $250 Deductible $500 Deductible

Gear coverage

Select Gear Coverage $1,000-$3,000 $3,000-$6,000

Roadside assistance

Please use the space below to add comments regarding any special circumstances or  coverage need

Driver #2 Information

Name

Date of Birth

Marital Status

Select Marital Status Divorced Married Separated Single Widowed

Driver’s license number

List all : states, foreign and international license(s)

Number of years licensed

Date of motorcycle license (if any)

List all citations received in the past 3 years
(Please include non-moving violation, type of violation, approximate date of violation).

List any suspensions of your license in the last 3 years. (Even if only for one day).

List any DUI ever received and approximate date of violation

List all accidents that were your fault

List all accidents that were NOT your fault

Motorcycle #2 Information

Year

Make

Madel

Vehicle ID Number

Body Style

Engine CC’s

List any club membership,
Goldwing, etc.

Date of any motorcycle safety course taken (if any)

Select Coverage and Limits Below

 Liability

Liability Limits

Select Liability Limits N/A State Minimum 50/100/25 100/300/50 250/500/500 300 CSL 500 CSL

 Un(der)insured Motorist-Will Match Liability

 Medical/Personal Injury Protection

 Comprehensive

Comprehensive Deductible

Select Comprehensive Coverage N/A $100 Deductible $250 Deductible $500 Deductible $1000 Deductible

  Collision

Collision Deductible

Select Collision Coverage N/A $50 Deductible $100 Deductible $250 Deductible $500 Deductible

Gear coverage

Select Gear Coverage $1,000-$3,000 $3,000-$6,000

Roadside assistance

Please use the space below to add comments regarding any special circumstances or coverage needs.

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