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ABOUT YOUR VEHICLE |
| Year: |
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| CCs: |
(if applicable) |
| # of Wheels |
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| Make: |
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| Model: |
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| Years of Experience: |
(with ATVs)
(with STREET motorcycles) |
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(with OFF ROAD motorcycles)
(with Golf Carts) |
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| Motorcycle License: |
Yes
No
When did you get it?
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(Not applicable to Golf Carts) |
| Street-Legal: |
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COVERAGE OPTIONS |
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Liability Limits: |
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Uninsured & Underinsured Motorist: |
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Kept in a locked structure? |
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Deductibles: |
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(if you want liability only, choose
that above) |
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Value: |
$
(current value in dollars if it is custom) |
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Usage:
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Do you have insurance? |
(if yes, with which
company)
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Groups: |
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Groups #2: |
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Do you want to include a trailer?
How much is it worth?
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Who referred you? |
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Please tell us if you have any tickets or accidents, when they were,
and the type. Provide additional information here. |
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Copyright 2011 Stratum
Insurance Agency, LLC |
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NO COVERAGE IS BOUND,
OFFERED, ISSUED THROUGH THIS ELECTRONIC COMMUNICATION, ALL POLICIES MUST BE
UNDERWRITTEN AND APPROVED BY THE CARRIER. DO NOT CANCEL YOUR CURRENT
INSURANCE. |
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