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Motorcycle Quote Request

No coverage bound until confirmed by one of our representatives

 

 

 

 

Name *

Address

City

State

Zip Code

Work Phone

Home Phone  *

Email Address *

Current Residence

 

 

Driver #1 Information

Name

Date of Birth

Marital Status

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

List any other registered owners

Motorcycle #1 Information

Year

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)

 

 

Select Coverage and Limits Below

 Liability

 

Liability Limits

 Un(der)insured Motorist-Will Match Liability Selection

 

 Medical/Personal Injury Protection

 

 Comprehensive

 

Comprehensive Deductible

 Collision

 

Collision Deductible

Gear coverage

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

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

 Un(der)insured Motorist-Will Match Liability

 

 Medical/Personal Injury Protection

 

 Comprehensive

 

Comprehensive Deductible

  Collision

 

Collision Deductible

Gear coverage

Roadside assistance

 

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

* Indicates required field

 

 

 

Williams Insurance Service

Email:  williams@wisservice.com

Yucca Valley Office

 

55898 Twentynine Palms Highway Suite E

Yucca Valley, CA. 92284

Phone: (760) 365-0758

Fax: (760) 365-3803

 

 

Twentynine Palms  Office

 

6259 Adobe Road

Twentynine Palms, CA. 92277

Phone: (760) 367-7542

Fax: (760) 367-9971

 

CA Ins. Lic. #: 0357222

 

 

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