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Home > Motorcycle > Motorcycle and Off-Road Vehicle
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Motorcycle and Off-Road Vehicle


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Principal Named Insured Information
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Vehicle Information
Policy Type

Vehicle Type






VIN
Year, Make, Model
CC Size:
Is the Motorcycle a trike?
Anti-Lock Brakes?
Purchase Year:
Garaging Zip Code
Special Hazard
Turbo or Nitrus Oxide Kit?
Modified Frame?
LoJack device installed on this vehicle?
Vehicle Use
Annual Miles Ridden
Primary Use


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Driver/Violation Information (Any operator in or outside the household with regular access to insured vehicle more than 12 times per year)
Driver's First Name
Middle Name
Last Name
Date of Birth *
/ /
Social Security Number
Gender
Marital Status
Driver's License Status
Motorcycle Endorsement?
State Filing
Approved Safety Course Completion
License State
License Number
Years Riding Experience
Second Named Insured
How often do you ride?
Violations- All comprehensive claims, accidents (both at fault and not at fault), and violations for the last 35 months:
Underwriting Information
Association Name
Primary Residence
Prior Motorcycle Liability Insurance
Prior Motorcycle Carrier
Prior Policy Period Expiration Date (MM/DD/YYYY)
Reason for new policy
HOG Membership Number
Coverage Information
Liability/Guest Passenger Limits
UM/UIM
UMPD
Med Pay
Comp/Coll Deductibles
Total Loss Coverage
Roadside Assistance
Disappearing Deductible
Trip Interruption
Transport Trailer
Accessory Coverage
Paint
Chrome
Wheels
Trike Kit
Saddlebags/Windshield
Pull Behind Trailer
Safety Apparel
Other
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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2005 W. Hamlin Rd. Suite 200
Rochester Hills, MI 48309

Ph: (586) 726-7800 | Fx: (248) 853-7063
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