MOTORCYCLE INSURANCE

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

CUSTOMER INFORMATION
First Name:
Middle Initial:
Last Name:
Sex: Male  Female
Date of Birth:
Social Security Number :
Telephone Number:
Marital Status: Married  Single  Other 
Home Address:
Driving Record
(prior 35 months):
Number of/Nature of Tickets
(all vehicles):
Number of/Nature of AF/NAF Auto/Motorcycle Accidents:
Automobile Driver License Status:
Email Address:
Primary Residence:
(Discount for Home ownership; includes ownership of Mobile Home if less than 10 years old.)

Own Home/Condo
 Own Mobile Home less than 10 yrs old
Rent
Live with Parents
Other

MOTORCYCLE / OFF-ROAD INFORMATION
Year:
Make:
Model:
CC Size:
Is the MC a Trike? Yes   No
Special Hazard (Turbo or nitrous oxide kit, modified frame)? Yes   No

Special Construction Determination:
Does the vehicle fall into one of the following categories?
(if so, physical damage coverage not available)
Homemade or composite Kit  
State-Assigned VIN Original frame has been replaced    
Non-factory built MC/Trike Not listed in the N.A.D.A. appraisal guide
 

UNDERWRITING INFORMATION
Garaging Zip Code:
Vehicle use
(i.e., pleasure, business, etc.):		 Pleasure  Business   Off-Road
Names of Regular Operators (Anyone with regular access to insured vehicle more than 12 times a year):
Names of Household
Resident Operators:
 
COVERAGE INFORMATION
Liability/Guest passenger Limits:
UM/UIM:
UMPD:
Med Pay:
Comp/Coll Deductibles:
Roadside Assistance:

Custom Parts or Equipment
Paint: $
Chrome: $
Wheels: $
Saddlebags/Windshields: $
Other: $
Total: $
 
Note To Customer (in credit states only): To provide an accurate quote, we have asked you numerous questions about yourself and your motorcycle. As part of the quoting process, we will also be utilizing various consumer reports which may include reports regarding your credit history. All information we acquire may be provided to our insurance carriers.


 

 
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321 S. Riverside Avenue - Box 190
Croton-on-Hudson, NY 10520-0190
(914) 271-5188
Fax (914) 271-9390

Hours: Monday - Friday 8:45- 4:45

E-mail: cathykaras@karasinsurance.com


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