Motorcycle Quote Form

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? *

Yes

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

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

List Accidents or Violations *

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

List Accidents or Violations *

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

Disabling Device?

Active

Passive

None

Any other units? *

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

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?

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