MOTORCYCLE QUOTE FORM

Date:

Referred by:

Name:

Address:

City: State: Zip:

Phone: Home Work

E-mail address:

Where is the bike kept? Garage Shed Basement

Do you currently have a Maine motorcycle license? YesNo

Violations within last 3 years? YesNo

Accidents within last 3 years? YesNo

Does your spouse have a bike license? YesNo

Does any driver need to file an SR-22? YesNo

If yes, please comment:

Has applicant passed an approved motorcycle safety course? YesNo

Can they provide proof? YesNo (Completion card, etc.)

UMB Member: YesNo Any other bike clubs?

(AMA, Hog, etc.)

Does applicant currently have insurance? YesNo

Company: Expiration date:

If not, have you had any in the last 6 months and can you provide proof of it?

YesNo

Description of Motorcycle

Year: Make:

Model:

CC's: Turbo: YesNo

Description of Motorcycle

Year: Make:

Model:

CC's: Turbo: YesNo

Please check desired coverage

Liability Limits

$125,000 50/100/25

$300,000 100/300/50

$500,000 250/500/100

Uninsured Motorist

$100,000 50/100

$300,000 100/300

$500,000 250/500

Passenger Liability: YesNo

Medical Payments

$1,000 $2,000 $5,000

Comprehensive Deductible

$100 $250 $500 $1,000

Collision Deductible

$100 $250 $500 $1,000

Accessories value:

Please check desired coverage .

Liability Limits

$125,000 50/100/25

$300,000 100/300/50

$500,000 250/500/100

Uninsured Motorist

$100,000 50/100

$300,000 100/300

$500,000 250/500

Passenger Liability: YesNo

Medical Payments

$1,000 $2,000 $5,000

Comprehensive Deductible

$100 $250 $500 $1,000

Collision Deductible

$100 $250 $500 $1,000

Accessories value:

Please use this space below for any additional information

that you would like us to have..