Motorcycle Quote
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9 - Motorcycle Quote
Please complete this form and attach copy of current policy if applicable. It will be sent to Karen DiVico, our Motorcycle Specialist.
ALL INFORMATION PROVIDED HERE WILL BE SENT to us SSL - SECURE SOCKET LAYER - ENCRYPTED for your security
Who told you about us?
Owner as titled
*
First
Last
Full Address (street #, City, State, Zip)
Owner's DOB
*
MM
/
DD
/
YYYY
Spouse NAme, DL # and DOB
DRIVERS LICENSE #
Owners SS #
Married
Yes
No
Gender
Male
Female
Best Number to call you
*
###
-
###
-
####
Alternate
###
-
###
-
####
Email
What will we find on your last three years driving record?
*
Do you own a home?
Yes
No
Have you owned and insured a motorcycle within the past 5 years?
Yes
No
Have you taken a MC Safety Foundation Course within the past 3 years?
Yes
No
Are you a member of a MC Association
Yes
No
Do you always wear a helmet?
Yes
No
Is motorcycle Garaged? Where?
Year, Make, Model, CC's with VIN# and value if you want Comp and Collision
*
Year, Make, Model, CC's with VIN# and value if you want Comp and Collision
Year, Make, Model, CC's with VIN# and value if you want Comp and Collision
Year, Make, Model, CC's with VIN# and value if you want Comp and Collision
Year, Make, Model, CC's with VIN# and value if you want Comp and Collision
Coverages
*
100,000 Liability
300,000 Liability
500,000 Liability
Uninsured Motorist
Comp/Collision 500 Ded
Comp/Collision 1000 Ded
Comp/Collision 2000 Ded
Comments
Upload a File (copy of current policy)
Tim Shaw Insurance Group, Inc.
239-939-1010,
or fax 239-939-7172.
4091 Colonial Blvd, Fort Myers, FL 33966
www.timshaw.com
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