SNOWMOBILE INSURANCE QUOTE
ABOUT THE OWNER
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
Drivers License:
Social Sec Num (Other than California, otherwise estimate)
Status	Single   Married  Widowed

 

ABOUT YOUR SNOWMOBILE
Year:		CCs:
Make:
Model:
Value:	$
Liability Limits:	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 15,000/30,000 20,000/40,000 - Minimum for MI 30,000/60,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000
	We always quote uninsured motorist 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
	If you choose liability only, we will also add Uninsured Motorist Bodily Injury and Property Damage for you if available.
Deductibles:	Collision: None CHOOSE ONE LIABILITY ONLY - I do not want full coverage $250 $500 $750 $1000 $2000 Comprehensive: None CHOOSE ONE LIABILITY ONLY - I do not want full coverage $250 $500 $750 $1000 $2000
Comprehensive Coverage?	CHOOSE ONE No Coverage $500 Deductible $250 Deductible $1000 Deductible $2000 Deductible
Other:	Towing Coverage
Associations:
	(If you belong to a snowmobiling or off-road association, please let us know)
Current Insurance:	None CHOOSE ONE YES - I have had continuous coverage for 6 months or more YES - but I have had a lapse in coverage of LESS than 30 days NO - I do not have insurance at this time YES- but I have had a lapse in coverage of MORE than 30 days Yes - 2 wheel ABS Which Company?   Length of Current Coverage (IF ANY): None CHOOSE ONE 1 Year 2 Years 3 Years 4 Years 5 Years More than 5
	Do you want to include a trailer? How much is it worth?
How did you hear about us?
	Please tell us if you have any tickets or accidents and the type (LAST 3 YEARS ONLY, UNLESS YOU HAVE A DUI, THEN 10 YEARS)

          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