MOTORCYCLE QUOTE SHEET
Referred by: _____________________________________________date:________________
(Please fill out top part of motorcycle quote sheet and fax to (352)-347-3525)
Name: ______________________________________________________________________________________________________
Address: (street)____________________________________________________________________________________________
(City)____________________________________ (state) ___________________(zip)_____________________
Phone #: ( ) _____________________________________________
e-mail address: ___________________________________________________________________________
Date of Birth:___________/___________/___________ Social Security #:_____________-___________-______________
Driver’s License #: ______________________________________________________________
Do you own a home: _____ Yes (or) _____ No
Do you have your motorcycle Endorsement: (license) _____Yes (or) _____No
Date the Policy is to take affect: __________/_________/__________
Gender: _____Male (or) _____Female Are you _____married (or) _____single?
Has rider owned an insured motorcycle in the past 12 months? _____Yes (or) _____No
(Proof of insurance is required) ID Card or Policy
Is motorcycle garaged ? _____Yes (or)_____No
Has the rider taken a motorcycle safety courses in the past 3 years? _____Yes (or) _____No
Does the rider belong to any motorcycle associations? _____Yes (or)_____No
Years of Riding experience: ______________
Do you have any tickets or accidents in the past 3 years? _____Yes (or) _____No If yes, provide
details:_______________________________________________________________________________________________________________
Motorcycle information
Year: _____________ Make: ________________________________Model: _________________________________
CC’s:______________ Purchase Price: $______________________ Additional Accessories: $________________
Motorcycle VIN #:_______________________________________________________________________________________________
Limits of Bodily Injury: (per $1,000) _____10/20 _____25/50 _____50/100 _____100/300
Uninsured Motorist: _____10/20 _____25/50 _____50/100 _____100/300 or _____reject coverage
Comprehensive & Collision Deductible: _____$250 _____$500_____$1000
Medical Payments: _____$1,000 _____$2,000_____$5,000 _____$10,000 or_____ reject coverage
Do you have health insurance? _____Yes (or)_____ No Ins. Company_____________________________
Lien holder information: (Name/Address)
_________________________________________________________________________________________________________________________________
Peterson Insurance Services / 14866 South East 25th Avenue, Summerfield, Florida 34491
Phone (352)-347-8478 / Fax (352)-347-3525
Email: Yourinsured @ aol .com / http://www.petersonins.com/
Insured with:_______________________________ Annual Premium $______________ Down payment $_______________
Credit Card :__________ Credit Card #_________________________________________exp. ____________ code#__________