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2022-07-29T00:27:06+00:00
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Agency Information
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Applicant Information - As Shown On License
Insured - First Name
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DOB
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SSN
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Country
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Afghanistan
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City
State
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Has applicant moved in last 6 months?
*
Yes
No
Prior Mailing Address
*
Country
United States (US)
United Kingdom (UK)
Canada
Australia
---
Afghanistan
Åland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
American Samoa
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belau
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Costa Rica
Croatia
Cuba
CuraÇao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Republic of Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Martin (Dutch part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (AA)
Armed Forces (AE)
Armed Forces (AP)
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
US Minor Outlying Islands
US Virgin Islands
Zip code
Location Address
*
Country
United States (US)
United Kingdom (UK)
Canada
Australia
---
Afghanistan
Åland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
American Samoa
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belau
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Costa Rica
Croatia
Cuba
CuraÇao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Republic of Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Martin (Dutch part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Email
Primary Phone number
*
**If any of the following apply, customer is not eligible for coverage: Requires an SR-22 financial responsibility filing, any vehicle held for sale or consignment, operator convicted of a felony, applicant or operator had license suspended, canceled, revoked or barred within the last 3 years, customer is not the titled owner of the unit(s) or if any unit has unrepaired or existing damage.
Requested Effective Date
*
Operator Information: List all licensed household members & regular use operators
First Name
*
Last Name
*
Gender
*
Male
Female
Date of Brith
*
Marital Status
*
Single
Married
Spouse is required to be listed as operator and may be excluded if requested.
Completed safety course in last 3 years?
Yes
No
Member of motorcycle association
*
Yes
No
List Association
*
Accidents or violations in the last 5 years?
*
Yes
No
List Accidents or Violations
*
Yes
No
Describe
Motorcycle Endorsement?
*
Yes
No
Any other operators?
Yes
No
First Name
*
Last Name
*
Gender
*
Male
Female
Date of Brith
*
Marital Status
*
Single
Married
Spouse is required to be listed as operator and may be excluded if requested.
Completed safety course in last 3 years?
Yes
No
Member of motorcycle association
*
Yes
No
List Association
*
Accidents or violations in the last 5 years?
*
Yes
No
List Accidents or Violations
*
Yes
No
Describe
Motorcycle Endorsement?
*
Yes
No
Unit Information
Has the applicant had continuous insurance or a lapse of less than or equal to 31 days?
*
Yes
No
Disabling Device?
Active
Passive
None
Any other units?
*
Yes
No
Unit type
*
Motorcycle
ATV/Utility
Dirt Bike
Golf Cart
Other
Describe Other:
*
VIN of unit
*
Is this a state assigned VIN?
*
Yes
No
Registered for Street use?
*
Yes
No
Model year
*
Manufacturer
*
CC’s
*
Model
*
Purchase date
*
Storage Type
*
Carport
Driveway
Off Street Parking
Locked Garage
Building
Parking Lot
Other
Describe Other:
*
Storage Construction
*
Frame
Masonry
Other
Describe Other:
*
Alarms?
*
Active
Passive
None
VIN Etching
Yes
No
Recovery System?
Yes
No
Coverages
Eligible Motorcycles 2 years or newer will be quoted with Replacement Cost or ACV Upon request. ATV/UTV/Golf Carts are not eligible for RCV.
Loss Settlement:
*
Replacement Cost
Actual Cash Value
Liability limits
*
$25,000/$50,000/$25,000
$50,000/$100,000/$25,000
$50,000/$100,000/$50,000
$100,000/$300,000/$50,000
$100,000/$300,000/$100,000
$250,000/$500,000/$100,000
$250,000/$500,000/$250,000
Uninsured Motorists
*
$25,000/$50,000
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000
Medical Payments
*
$1,000
$2,500
$5,000
$10,000
Coverages requested (check all that apply)
Deductible
Diminishing Deductible
Accessories ($3000 included)
Personal Effects
Towing
Rental Reimbursement
Travel Loss
Value of Trailer Designed and Used for the Motorcycle/ATV/UTV
Discounts & Surcharges (check all that apply)
More than 1 policy with American Modern
Applicant own primary residence
Will applicant be paying in full
Will applicant enroll in paperless policy delivery
Any Additional Questions or Comments?
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