In order to provide you with a quote and to determine your eligibility for our programs that we offer through various carriers, our agency and/or companies we represent may use information contained in credit, MVR reports, insurance loss history, and other various consumer reports. In order to provide you with a quote, our carriers may also develop a credit-based insurance score using these reports and sometimes this is accomplished by using a third party. For additional information on collection and disclosure of personal information, and your right to see and have the opportunity to correct any personal information in your files, please contact our office. The reports provide us and/or our carriers with information that assists with determining your eligibility for insurance and the final price you are charged. By completing these forms, you agree to this process in making a request for a quote.
Full name
*
Street address
*
City
*
State
*
Zip Code
*
Email address
Daytime telephone
Evening telephone
Best time to reach you
Number of years at current address
Do you own a home?
Current Insurance Information
Insurance company name (not broker/agency)
Policy expiration date
Term
Premium amount
How long with current
Motorcycle Information
Motorcycle 1
Year
*
Make/Model
*
Engine size (cc)
*
Yearly mileage
*
Usage
Type
List any special equipment you want insured on this motorcycle. Please include value.
Motorcycle 2
Year
Make/Model
Engine size (cc)
Yearly mileage
Usage
Type
List any special equipment you want insured on this motorcycle. Please include value.
Coverage Information
Motorcycle 1
Liability limits for bodily injury and property damage
Uninsured motorist bodily injury
Motorcycle 2
Liability limits for bodily injury and property damage
Uninsured motorist bodily injury
Deductibles
Motorcycle 1
Comp. & Collision
Towing coverage
Rental reimbursement
Motorcycle 2
Comp. & Collision
Towing coverage
Rental reimbursement
Operator Information
Operator 1
Name
*
Date of birth
*
Drivers license number
*
Years licensed
*
Number of years cycling experience
*
Occupation
Gender
Motorcycle Safety Foundation Course
Minor violations in last 5 years (speeding/turn/stop sign/red light/etc)
Non-chargeable accidents in the last 5 years
Chargeable accidents in the last 5 years
Chargeable accident cost ($)
Major violations in the last 5 years (drunk driving/reckless/hit and run/etc.)
Operator 2
Name
Date of birth
Drivers license number
Years licensed
Number of years cycling experience
Occupation
Gender
Motorcycle Safety Foundation Course
Minor violations in last 5 years (speeding/turn/stop sign/red light/etc)
Non-chargeable accidents in the last 5 years
Chargeable accidents in the last 5 years
Chargeable accident cost ($)
Major violations in the last 5 years (drunk driving/reckless/hit and run/etc.)
Any additional comments or information that might be helpful
By completing this form you are acknowledging your understanding of and agreement with the following terms:
1. No coverage of any kind is bound or implied by submitting information via this online form.
2. Information from you and other sources such as your driving claims and insurance histories may be used to calculate an accurate price for your insurance.
3. We will not distribute information to other parties other than for insurance underwriting purposes.
4. We value your privacy. Every precaution has been taken to insure your privacy and security.
5. By submitting this form you agree to release us from any liability should this information be accidentally viewed by others.
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We currently provide insurance services in:
North Carolina
South Carolina
Virginia
Please note: Changes to policies via this website are not effective or binding until you, or any party involved, receive official notification from your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.
