Peterson Insurance Services

14866 South East 25th. Avenue Summerfield, Florida 34491 (352) 347-8478

ATV QUOTE SHEET

Complete the following information if you would like to obtain a quote on a ATV insurance policy. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for your  ATV..

(Fill in your information and press your TAB button to continue to the next question...)

*  Owner's :  * e-mail address:  * Phone # :

*  Street :  *  City:  *  State:  *  Zip:

* Rider (1) Date of Birth :  *   Social Security#   *    Driver’s License # :

*  State of license:   *  Years of experience: (riding a motorcycle)

*  How did you hear about us?  

*  Married , Single or Widowed ? : *   Gender:

*  Do you own a home:   *  Homeowners insurance company

*  Is motorcycle garaged? :

*  Date the policy is to take effect:

*  Have you had insurance for the past 12 months on a ATV ? : (Proof of insurance will be required, copy of  ID card or policy)

*  Have you taken any ATV safety courses ? :

*  Do you  have any tickets or accidents in the past 3 years ? :

*  If yes, provide details :

    ATV(s)  Information:                                                    

ATV  (1)

*  Year : * Make :   *   Model :  * CC’s :                                                     

*  Purchase Price :$    *  Additional Accessories: $        * ATV  VIN# :

 ATV  (2)                                            

*  Year : * Make :   *   Model :  * CC’s :                                                     

*  Purchase Price :$    *  Additional Accessories: $       * ATV  VIN# :

        Coverage's  / Limits                                                                            

*  Limits of Liability :  * Uninsured Motorist :  * Comp.& Collision Deductible :

*  Medical Payments :  

     Additional Info. :             

* Rider (2)  Name:    * Date of Birth :  

*   Social Security#   *   Driver’s License # : 

 

Thank you for taking the time to complete our  quote sheet, Peterson Insurance Services will contact you with a  competitive quote with in 24 hours !!