Insurance Motorcycle Application Form

INSURANCE MOTORCYCLE APPLICATION FORM

Applicant Name:

Applicant Information

Motorcycle Information

Year:    Make:    Model:

Commute    Pleasure    Business / Commercial    Annual mileage:

Security & Storage

Garaging Address (if different):

Anti-theft / Security Devices (check all that apply):
Alarm System    GPS Tracking    Disc Lock / Chain    None

Insurance & Driving History

Have you had any accidents or claims in the past 5 years?   Yes   No

Any DUI, DWI, license suspension or revocation in the past 7 years?   Yes   No

Coverage Requested

Select coverage options (check all desired):
Liability (Bodily Injury & Property Damage)    Collision    Comprehensive    Uninsured/Underinsured Motorist    Medical Payments    Roadside Assistance / Towing

Policy Period

Requested Effective Date:    Requested Expiration Date:

Discounts & Endorsements

Applicable discounts (check all that apply):
Multi-Policy    Safe Rider Course    Anti-Theft Device    Good Driver

Required Documentation Checklist

Attach or provide the following documents as applicable (check when attached):
Copy of Motorcycle Driver's License    Vehicle Title/Registration    Prior Policy Declarations Page    Photos of Vehicle

Beneficiary Designation (for Medical Payments / Death Benefit)

Exclusions and Limits

The policy applied for will not cover loss or liability arising from intentional acts, operation of the vehicle while under the influence of alcohol or controlled substances, use of the vehicle for illegal activities, operation by an unlicensed or excluded operator, or use in organized racing events. Limits, exclusions and conditions stated in the insurer's policy form will apply. Coverage is subject to underwriting approval and policy terms.

Representation, Authorization, and Certification

I represent that the information provided in this application is true and complete to the best of my knowledge. I understand that any material misrepresentation, omission, or incorrect statement may be grounds for rescission of coverage or denial of a claim. I authorize the insurer, its representatives and agents to obtain and verify driving records, insurance claims history, and other consumer or investigative reports as necessary to determine eligibility for coverage and premium calculation. I further authorize release of information to and from prior insurers for underwriting and claim investigation purposes.

I acknowledge that coverage is not binding until acceptance by the insurer and issuance of a policy. Any binder or temporary coverage provided is subject to the terms, conditions and limitations specified at the time such binder is issued. I agree to notify the insurer promptly of any changes in the facts stated in this application prior to policy inception.

Fraud Warning: Any person who knowingly presents false information in an application for insurance may be subject to civil and criminal penalties and denial of coverage.

Additional Information / Remarks

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