Motorcycle, Snowmobile, Golf Cart, ATV, UTV Scooter, Moped Questionnaire

URL

This field is for validation purposes and should be left unchanged.

Full Name(Required)

Home Address

Phone Number

Email Address(Required)

Please provide the following information for EACH DRIVER:

Full Name

Date of Birth

Marital Status

Driver's License Number

Motorcycle Endorsement on DL

Yes

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

Year, Make & Model

CCs

VIN Number

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 Information

List ALL Coverages

Loss Settlement Type

If not insured, please list reason & date coverage went out of force

Additional Information

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.