Premier Services - The Insurance Experts

Motorcycle Insurance Application
(Quotes will be provided for Pennsylvania)

Name:

Address:

City, State, Zip Code:

Phone:

Fax:

E-Mail:

Please list all drivers residing in the household and list all moving violations and at-fault accidents within the last three years. List major violations, such as DUIs and suspensions within the last five years:

Driver #1

Name:

Age:

Marital status:

Sex:

Years licensed:

License number:

Violations (include dates):

Driver #2

Name:

Age:

Marital status:

Sex:

Years licensed:

License number:

Violations (include dates):

Motorcycle #1

Year:

Make:

Complete model name and number:

VIN or serial number:

Displacement in CC:

Value:

Vehicle Code:

Motorcycle #2

Year:

Make:

Complete model name and number:

VIN or serial number:

Displacement in CC:

Value:

Vehicle Code:

Coverages

Current insurance carrier:

Effective date:

Premium paid:

Liability limits:

Medical payment:

Uninsured motorist:

Underinsured motorist:

Stacked uninsured motorist Yes No

Stacked underinsured motorist Yes No

Do you have quotations from other companies? Yes No

Would you like a quote from us for the same coverage for easy comparison? Yes No

Who is the insurance company?

What coverage was quoted?

What was the price quoted?

How did you hear about us?

Additional Comments: