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REQUEST A QUOTE  --  Motorcycle
All Modern Makes and Models, Antique and Classic Motorcycles, Custom Motorcycles
 

Click here to download a Microsoft Word printable "Request for Quote" form that you can mail in.
 

Or, fill out the below form and hit "submit".

 

Primary Driver    Phone

Address    Date of Birth   

City     State    Zip   
Quotes provided for Illinois, Iowa and Wisconsin residents only.


Social Security Number     (optional)

County

 

E-Mail Address

Do you own   or rent your home?

Years Motorcycle Driving Experience   

Years Automobile Driving Experience   

Gender      Marital Status

Name & Date any Accidents or Moving Violations in the last 5 Years

Name Other Driver(s) in Household 
   
 

List Memberships in Motorcycle Clubs and Organizations  

Date of last Motorcycle Safety Class    AMA Member? 

Make & Model of Vehicle  Year

Engine Size (cc)
List any Engine Modifications

List any Accessories added to Stock Model

If 19 years or older, List any Restorations or Modifications

Approximate Current Market Value 
Any Liens/Leases?
 

Estimated Annual Mileage  Garaged Zip

Name Existing Insurance Carrier on this Vehicle, if any

Name Insurance Companies used for any Other Motorcycles

Additional Vehicles  

Desired Effective Insurance Date 

Liability/PD Coverage?
20/40/15   25/50/25    50/100/50     100/300/50     250/500/250

Uninsured/Underinsured Coverage Same as Liability, unless requested otherwise 

Medical Payments?   None    1000    2500    5000    10,000   

Comprehensive (fire & theft)? Yes   No   Deductible  250   500   1000   

Collision?      Yes    No    Deductible   250    500    1000   

Other Notes and Information:

Note: When providing a quotation for an insurance premium, insurance companies may review your credit report and your driving record. No insurance coverage is bound until a) we provide a quote using the information provided here and b) we receive your completed application and premium payment.




Voice  630-204-4178    Fax  815-732-1320
info@callriderschoice.com
P.O. Box 14   Oregon, IL   61061

             
             
             

Copyright 2004-2006, Riders Choice Insurance Agency, Inc., all rights reserved