Segway Insurance Quote Request 

 

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
Birthday:
E-mail:
Confirm E-mail:
Home Status:	CHOOSE ONE Own Home Own Condo Rent Live with Family
Gender:	CHOOSE ONE Male Female
Serial Number (if available):
Drivers License:
Social Sec Num (Not for CA, for accurate quote, otherwise estimate)
Status	Single   Married  Widowed

About Your SegWay

 

Year:
Make:
Model:
Limits:	Liability:   15,000/30,000/10,000 250,000/500,000/100,000 25,000/50,000/10,000 30,000/60,000/15,000 50,000/100,000/25,000 100,000/300,000/50,000 250,000/500,000/100,000 300,000 Combined Single Limit 500,000 Combined Single Limit
	Uninsured Motorist: 15,000/30,000/5,000 250,000/500,000 30,000/60,000/25,000 25,000/50,000/15,000 50,000/100,000/25,000 100,000/300,000/50,000
	Uninsured Motorist Property Damage: No Coverage $3,500
	Would you like comprehensive/collision? If so, please choose a deductible below.
Collision:	None CHOOSE ONE NONE $100 $250 $500 $750 $1000 $2000
Comprehensive (Theft):	None CHOOSE ONE LIABILITY ONLY - I do not want full coverage $100 $250 $500 $750 $1000 $2000
Motorcycle License:	Yes     No     When did you get it?
	Have you taken a motorcycle safety course? Yes No
Options:	Roadside Assistance ($8-$15 per policy)
	Please tell us if you have any tickets or accidents and the type. Also use this area for comments and questions.

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 2008 Stratum Insurance Agency, LLC