McAlpin Agency, Inc. Motorcycle Insurance Quote Request Form for Minnesota MN Allied Progressive Foremost Dairyland

This is a request for a Minnesota motorcycle quote, not a policy application. Submitting this form does not obligate you to purchase any motorcycle insurance products. Please complete this form as accurately as possible. Motorcycle insurance rates are subject to change.

General Information

Name
Street
City, State ZIP
E-mail
Phone
FAX
Agent Request

Residence Information

Primary Residence
Months at Address

Current Motorcycle Insurance Information

Current Company
Expiration Date
Months With Company

Driver Information (please list all drivers)

Driver #1
Name	Birth date	Sex	Marital Status	Years Experience

Social Security #		Driver License #
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)
Rider Group Association		If a Rider Safety Course has been completed, please enter date

Comment

Driver #2
Name	Birth date	Sex	Marital Status	Years Experience

Social Security #		Driver License #
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)
Rider Group Association		If a Rider Safety Course has been completed, please enter date

Comment

Percentage of Use

	Driver 1.	Driver 2.
Motorcycle 1.
Motorcycle 2.

Motorcycle Information

Motorcycle 1.
Year	Make	Model	Number of CC's

Garaged	Anti-theft Alarm	Use	Years Owned
Yes No	Yes No
Describe any special equipment including cost when new & any alterations from manufacturer's specifications

Motorcycle 2.
Year	Make	Model	Number of CC's

Garaged	Anti-theft Alarm	Use	Years Owned
Yes No	Yes No
Describe any special equipment including cost when new & any alterations from manufacturer's specifications

Coverage's

Liability Coverage. Pays for other people's injuries and damage to their property if you or someone else cause an accident while driving your motorcycle. It protects your assets in the event you are held liable for damage to others.
Bodily Injury Liability		Comment
Property Damage Liability

Medical Expense Coverage. If you and your passengers are injured in an motorcycle accident, this coverage pays your medical expenses.
Medical Expense		Comment

Uninsured and Underinsured Operator Coverage. Pays bodily injury claims if you or your passengers are injured by a negligent uninsured operator, hit-and-run operator or a negligent operator without adequate insurance.
Uninsured/Underinsured Operator		Comment

Comprehensive Coverage. Pays for damage to your motorcycle caused by theft, fire, windstorm, vandalism and many other non-collision occurrences. Collision Coverage. If your motorcycle collides with another vehicle or object, this coverage pays to repair your motorcycle.
	Motorcycle 1.	Motorcycle 2.
Comprehensive Deductible
Collision Deductible

Comments

Last modified: February 07, 2011