Motorcycle Quote Form

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

Agency Information

Agency Name *

Agency Code *

Email *

Agent First Name *

Agent Last Name *

Phone *

Applicant Information - As Shown On License

Insured - First Name *

Insured - Last Name *

DOB *

SSN

Current Mailing Address *

Country

City

State

Zip code

Has applicant moved in last 6 months? *

Prior Mailing Address

Country

City

State

Zip code

Location Address *

Country

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

Operator 1 (Named Insured)

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

Member of motorcycle association *

Yes

List Association *

Accidents or violations in the last 5 years? *

Yes

Describe

Motorcycle Endorsement? *

Yes

Any other operators?

Yes

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

Member of motorcycle association *

Yes

List Association *

Accidents or violations in the last 5 years? *

Yes

Describe

Motorcycle Endorsement? *

Yes

Unit Information

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

Yes

Unit type *

Describe Other: *

VIN of unit *

Is this a state assigned VIN? *

Yes

Registered for Street use? *

Yes

Model year *

Manufacturer *

CC’s *

Model *

Purchase date *

Describe Other: *

Storage Construction *

Frame

Masonry

Other

Describe Other: *

Alarms? *

Active

Passive

None

VIN Etching

Yes

Recovery System?

Yes

Disabling Device?

Active

Passive

None

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 *

Uninsured Motorists *

Medical Payments *

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? 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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Motorcycle Quote Submission

Agency Information

Applicant Information - As Shown On License

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

Operator 1 (Named Insured)

Unit Information

Coverages