In order to receive preliminary insurance and initial quote information please fill and send in the following form. Thank you!
NAME
GARAGE ADDRESS
CITY STATE ZIP
MALE FEMALE MARRIED SINGLE DATE OF BIRTH (mm/dd/yyyy) / /
YEAR / MANUFACTURER / MODEL / CC SIZE / ANNUAL MILEAGE (est.) Under 7,500 7,501 - 15,000 15,000+
CUSTOM / MODIFIED --- Yes No If the motorcycle was modified, what was done, and how much was spent?
MOTOR VEHICLE RECORD (last 3 years) (ie. accidents, violations)
COVERAGE / LIMITS DESIRED Please check where applicable. Bodily Injury Liability Limit of liability 25/50k 50/100k 100/300k 250/500k
Property Damage Liability Limit of liability 25k 50k 100k 250k Medical Payments Limit of liability $1,000 $5,000 $10,000 Uninsured / Motorists Bodily Injury / Underinsured Limit of liability 25/50k 50/100k 100/300k 250/500k
Uninsured Motorist Property Damage
Comprehensive Deductibles Deductible $500 $1,000 $2,500
Collision Deductibles Deductible $500 $1,000 $2,500
Towing Rental Reimbursement Waiver of Collision Deductible
Guest Medical Limit of liability $1,000 $5,000 $10,000
Guest Passenger Liability
General Comments / Additional Questions
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Thank you for your time! - Plaza Insurance Sales, Inc.
