Motorcycle, Snowmobile, Golf Cart, ATV, UTV Scooter, Moped Questionnaire Full Name (First, MI, Last): Home Address: Phone Number Email Address Please provide the following information for EACH DRIVER: Full Name Date of Birth Marital Status Driver's License Number Motorcycle Endorsement on DL YesNo Years Riding Experience Exterior construction Safety Course Taken (Type & Date) Rider Associations/Memberships List ALL auto & recreational vehicle accidents, tickets, claims & violations in the last 5 years Please provide the following information for EACH VEHICLE: Type —Please choose an option—MotorcycleTrikeSnowmobileGolf CartATVUTVScooterMoped Year, Make & Model CCs VIN # Annual Mileage Purchase Year Primary Driver LoJack, ABS, Nitrus, Modified Frame or other features Describe Existing Damage Usage (commute, pleasure, racing, trail, etc) How often used during ride season Zip Code where primarily used Total Value (not including after-market parts or accessories) (Is this value a current Market Value, a Replacement Value, or a purchase receipt including tax & title fees value?) Value & Type of Accessories & After-Market Parts Trailer Coverage Desired (If yes, Year, Make, Model, Type & Value) Current Insurance Info: Current Insurance Company & Due Date List ALL Coverages (BI/PD | Comp Deductible | Med Pay | Collision Deductible | UM/UIM BI | UMPD | Accessories | Other Coverages) Loss Settlement Type —Please choose an option—Total Loss ReplacementAgreed ValueACV If not insured, please list reason & date coverage went out of force Additional Info: Additional Drivers Additional Vehicles Additional Insured Do you own a home or rent? If you have a copy of your current "Declaration Page", please forward that to us as proof of prior coverage and to use for comparison purposes. Submission of information for a quote in no way binds coverage. Personal information will be used solely for underwriting purposes. Submission of information gives the Gary J Bach Agency permission to run all reports necessary to quote accurate insurance premiums.
