ABOUT THE RIDER
First Name:
Last Name:
Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Phone:	Zip Code
County:	Municipality (Ohio Only):
Birthday:
E-mail:
Confirm E-mail:
Home Status:	CHOOSE ONE Own Home Own Condo Rent Live with Family
Gender:	CHOOSE ONE Male Female
VIN (if available):	(17 digits)
	Where can I find my VIN? (pop-up)
Drivers License:
Social Sec Num (Outside California, for accurate quote, otherwise estimate)
Status	Single   Married  Widowed

 

ABOUT THE CAN AM SPYDER
Year:		CCs:
Make:
Model:
Salvaged Title:	CHOOSE ONE NO YES
COVERAGE OPTIONS
Liability:	CHOOSE ONE 15,000/30,000/5,000 - Minimum for CA 15,000/30,000/10,000 - Minimum for AZ 20,000/40,000/10,000 - Minimum for MI 30,000/60,000/25,000 25,000/50,000/15,000 50,000/100,000/25,000 100,000/300,000/50,000 250,000/500,000/100,000 500,000/500,000/250,000
Uninsured Motorist:	CHOOSE ONE NONE REQUESTED 15,000/30,000/5,000 - Minimum for CA 15,000/30,000/10,000 - Minimum for AZ 20,000/40,000/10,000 - Minimum for MI 30,000/60,000/25,000 25,000/50,000/15,000 50,000/100,000/25,000 100,000/300,000/50,000
	We always quote uninsured motorist coverage, unless specifically instructed not to do so.
Medical Payments:	CHOOSE ONE NONE $1000 $2000 $5000 $10000 $15000 $25000 $50000
Coverage Types:	Liability Only Quote    Full Coverage
Deductibles:	None CHOOSE ONE LIABILITY ONLY - I do not want full coverage $250 $500 $750 $1000 $2000
M1 License:	Yes     No     When did you get it?
Accessories Coverage:	$ Amount of accessories:
Antitheft:	None CHOOSE ONE Lo-Jack TeleTrac Basic Alarm - No Tracking
Current Coverage:	If you have insurance, what do you currently pay and with whom?
Groups:	CHOOSE ONE NONE American Dune Buggy / Sand Association ABATE AMA - American Motorcycle Association BRAG - Buell Riders Adventure Group BMWMOA - BMW Motorcycle Owners of America Ducati Unlimited GWRRA - Gold Wing Road Riders Association HOG RAT - Riders Association Triumph STAR Riders Association Honda Riders Club of American
Groups #2:	CHOOSE ONE NONE American Dune Buggy / Sand Association ABATE AMA - American Motorcycle Association BRAG - Buell Riders Adventure Group BMWMOA - BMW Motorcycle Owners of America Ducati Unlimited GWRRA - Gold Wing Road Riders Association HOG RAT - Riders Association Triumph STAR Riders Association Honda Riders Club of American
License Status:	CHOOSE ONE Valid / Current Supsended Permit Revoked International Only Not Licensed
Safety Course Completed:	CHOOSE ONE Yes - within the last 3 years Yes - MORE than 3 years ago No
SR-22 filing required	CHOOSE ONE Yes - DUI Yes - Accident related No
	Please tell us if you have any tickets and/or at-fault accidents.  List the dates, types, and if available, violation number.
	Do you have any additional information, special coverage needs or questions to ask?
	Did you complete your birthday and zip code? These are crucial to us obtaining an accurate quote. Make sure to check your "junk" or "spam" boxes, as our quotes sometimes go there.  Thank you!

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.

Copyright 2007 Stratum Insurance Agency, LLC