Contact Information

Name
Address
City, State ZIP
Phone
E-Mail
FAX

Underwriting Questions

Residency Status: Do you own a     house?     yes   no	select one ......... own house own mobilehome rent live with parents other
Do you have prior riding and     operating experience?     yes   no	.......... 0 1 2 3 4 5+   Years
Do you currently have insurance?     If yes, company    yes   no	Expiration Date

Driver #1	Name
Birthdate	Sex    male  female	Marital     Status   single  married
License #        SSN #

Driver #2	Name
Birthdate	Sex    male  female	Marital     Status   single  married
License #        SSN #

Driver #3	Name
Birthdate	Sex    male  female	Marital     Status   single  married
License #        SSN #

Driver #4	Name
Birthdate	Sex    male  female	Marital     Status   single  married
License #        SSN #

Traffic Violations

List all minor violations (speeding, stop sign, etc.) for the last 3   years, and all major violations (DWI, reckless driving, etc.) for   last 5 years.  List the DRIVER, DATE, and TYPE OF VIOLATION.

Accidents

List all accidents which occurred in the last 3 years. List the   DRIVER, DATE, FAULT, AMOUNT, and a BRIEF DESCRIPTION.

Vehicle #1

Type select.......... 4 wheeler motorcycle golf cart snowmobile

Year

Make

Model

CCs

Serial Number

Vehicle #2

Type select.......... 4 wheeler motorcycle golf cart snowmobile

Year

Make

Model

CCs

Serial Number

Vehicle #3

Type select.......... 4 wheeler motorcycle golf cart snowmobile

Year

Make

Model

CCs

Serial Number

Vehicle #4

Type select.......... 4 wheeler motorcycle golf cart snowmobile

Year

Make

Model

CCs

Serial Number

Liability - Bodily Injury Limits	select one of these .......... $25,000 / $50,000 $50,000 / $100,000 $100,000 / $300,000 $250,000 / $500,000
Liability - Guest Passenger Limits	select one of these .......... No Coverage $25,000 / $50,000 $50,000 / $100,000 $100,000 / $300,000 $250,000 / $500,000
Liability - Property Damage Limit	select one of these .......... $25,000 $50,000 $100,000 $250,000
Medical Payments Limit	select one of these .......... No Coverage $1,000 $2,000 $5,000
Uninsured Motorists Limits	(same as Bodily Injury limits)
Underinsured Motorists Limits	(same as Bodily Injury limits)

	Vehicle 1	Vehicle 2	Vehicle 3	Vehicle 4
Comprehensive Deductible	select one .... no coverage $100 ded. $250 ded. $500 ded. $900 ded. $1,000 ded.	select one .... no coverage $100 ded. $250 ded. $500 ded. $900 ded. $1,000 ded.	select one .... no coverage $100 ded. $250 ded. $500 ded. $900 ded. $1,000 ded.	select one .... no coverage $100 ded. $250 ded. $500 ded. $900 ded. $1,000 ded.
Collision Deductible	select one .... no coverage $100 ded. $250 ded. $500 ded. $900 ded. $1,000 ded.	select one .... no coverage $100 ded. $250 ded. $500 ded. $900 ded. $1,000 ded.	select one .... no coverage $100 ded. $250 ded. $500 ded. $900 ded. $1,000 ded.	select one .... no coverage $100 ded. $250 ded. $500 ded. $900 ded. $1,000 ded.
Value of Custom Equipment	$	$	$	$

Comments

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