Motorcycle Quote Submission

Please complete the following form to receive a motorcycle quote. After completion, our underwriter will get back with you.

Motorsports Quote

Agency Information

Agency Name *

Agency Code *

Email *

Agent First Name *

Agent Last Name *

Phone *

Applicant Information

Insured - First Name & Last Name *

DOB *

SSN

Current Mailing Address *

Country

City

State

Zip code

Has applicant moved in last 6 months? *

Yes

Prior Mailing Address

Country

City

State

Zip code

Is the mailing address the same as the location address? *

Yes

Location Address *

Country

City

State

Zip code

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 *

Unit type *

Describe Other: *

Discounts & Surcharges (check all that apply) *

More than 1 American Modern policy with Graham-Rogers

Applicant will be paying in full

Applicant enroll in paperless policy delivery

Applicant owns primary residence

American Modern Policy Number: *

Has the applicant had continuous insurance or a lapse of less than or equal to 31 days? *

Yes

Operator Information: List all licensed household members & regular use operators

Operator 1 (Named Insured)

Drivers

First Name *

Last Name *

Date of Brith *

Gender *

Male

Female

Spouse is required to be listed as operator and may be excluded if requested.

Motorcycle Endorsement? *

Yes

Member of motorcycle association *

Yes

List Association *

Completed safety course in last 3 years? *

Yes

Date completed? *

Accidents or violations in the last 5 years? *

Yes

Describe: Include date, amount & fault: *

Add operator 2? *

Yes

2. First Name *

2. Last Name *

2. Gender *

Male

Female

2. Date of Birth *

2. Relationship to insured *

Spouse

Child

Other - Specify:

2. Motorcycle Endorsement? *

Yes

2. SSN

2. Member of motorcycle association? *

Yes

2. List Association: *

Driver 2 Accidents or violations in the last 5 years? *

Yes

Driver 2 Describe: Include date, amount & fault: *

Has Driver 2 completed safety course in last 3 years? *

Yes

Date driver 2 completed? *

Exclude Driver 2? *

Yes

Add operator 3? *

Yes

3. First Name *

3. Last Name *

3. Gender *

Male

Female

3. Date of Birth *

3. Relationship to insured *

Spouse

Child

Other - Specify:

3. Motorcycle Endorsement? *

Yes

3. SSN

3. Member of motorcycle association? *

Yes

3. List Association: *

Driver 3 Accidents or violations in the last 5 years? *

Yes

Driver 3 Describe: Include date, amount & fault: *

Has Driver 3 completed safety course in last 3 years? *

Yes

Date driver 3 completed? *

Exclude Driver 3? *

Yes

Add operator 4? *

Yes

4. First Name *

4. Last Name *

4. Gender *

Male

Female

4. Date of Birth *

4. Relationship to insured *

Spouse

Child

Other - Specify:

4. SSN

4. Motorcycle Endorsement? *

Yes

4. Member of motorcycle association? *

Yes

4. List Association: *

Driver 4 Accidents or violations in the last 5 years? *

Yes

Driver 4 Describe: Include date, amount & fault: *

Has Driver 4 completed safety course in last 3 years? *

Yes

Date driver 4 completed? *

Exclude Driver 4? *

Yes

Add operator 5? *

Yes

5. First Name *

5. Last Name *

5. Gender *

Male

Female

5. Date of Birth *

5. Relationship to insured *

Spouse

Child

Other - Specify:

5. SSN

5. Motorcycle Endorsement? *

Yes

5. Member of motorcycle association? *

Yes

5. List Association: *

Driver 5 Accidents or violations in the last 5 years? *

Yes

Driver 5 Describe: Include date, amount & fault: *

Has Driver 5 completed safety course in last 3 years? *

Yes

Date driver 5 completed? *

Exclude Driver 5? *

Yes

Unit Information

VIN/Serial Number *

Is this a state assigned VIN? *

Yes

For homemade or rebuilt vehicles

Model year *

Manufacturer *

Model *

CC’s *

Purchase date *

Is the unit salvaged/rebuilt? *

Yes

Is the unit a classic? *

Yes

Is the unit a custom unit? *

Yes

Is the unit have any modifications? *

Yes

Explain modifications:

Registered for Street use? *

Yes

Explain usage: *

Is the Storage address different than the location address? *

Yes

Storage Address *

Country

City

State

Zip code

Storage Construction *

Frame

Masonry

Other

Describe Other: *

Alarms? *

Active

Passive

None

Disabling Device? *

Active

Passive

None

VIN Etching *

Yes

Vehicle Recovery/Tracking System? *

Yes

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.

Liability limits *

Medical Payments *

Uninsured Motorists *

Deductible for Comprehensive: *

Would the applicant like Collision coverage? *

Yes

Deductible for Collision: *

Accessories Coverage *

Towing and Emergency Expense *

Rental Reimbursement *

Any Additional Questions or Comments? If there is more than 1 Unit, please provide responses for all of the Unit Information questions for each additional unit in this box.

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