Motorcycle and ATV Insurance Application

MOTORCYCLE AND ATV INSURANCE APPLICATION

Applicant Information

Vehicle Information — Vehicle 1

Alarm    GPS Tracking    Disc Lock / Wheel Lock    None

Additional Vehicle (Optional) — Vehicle 2

Drivers Residing with Applicant

List all persons residing in applicant's household who may operate insured vehicles. For additional drivers, attach separate sheet if necessary.

Coverage Selection

Select desired coverages. Limits and deductibles selected below will apply per policy declaration upon issuance.

Liability Coverage    Limits: $

Collision Coverage    Deductible: $

Comprehensive Coverage    Deductible: $

Uninsured / Underinsured Motorist    Limits: $

Medical Payments / PIP    Limit: $

Roadside Assistance / Towing    Limit / Service:

Policy Details & Payment

Requested Effective Date:    Policy Term (months):

Payment Plan:    Annual    Semi-Annual    Monthly

Exclusions and Limitations

The following are examples of typical exclusions under this application and are not intended to be a complete list. Coverage will not apply to loss, damage or liability arising from: (a) intentional acts by the insured; (b) use of the vehicle in a race, speed contest or stunt activity; (c) operation by any person who is not permitted to drive under the policy or who is excluded by endorsement; (d) wear and tear, mechanical breakdown, or gradual deterioration; (e) use of the vehicle for hire, livery, or carrying passengers for a fee unless specifically endorsed; (f) loss arising from war, nuclear hazard, or government seizure; and (g) vehicles modified for competitive racing unless specifically scheduled and approved in writing.

Beneficiary Designation (for Medical Payments / PIP or death benefits)

Documentation Checklist

Please attach required documentation to this application. Check all items included with submission.

Copy of Driver's License    Vehicle Registration    Photos of Vehicle    Prior Policy Declarations

Declarations, Authorization and Fraud Warning

By signing below, I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that knowingly submitting false information or omitting material information may result in denial of coverage, rescission of the policy, or other remedies provided by law. I acknowledge that completion of this application does not bind the insurer to provide coverage; coverage will be effective only upon issuance of a policy and receipt of required premium unless otherwise agreed in writing by an authorized representative.

I authorize any prior or current insurer, employer, and motor vehicle licensing agency to release my loss, claims, driving and underwriting records to the insurer and its representatives for purposes of underwriting, rating, or claim handling. I authorize the insurer to obtain motor vehicle records and credit information, where permitted by law, for underwriting and billing purposes. This authorization applies to the applicant and any drivers listed on this application.

Fraud Notice: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against the insurer, submits an application or files a claim containing false, incomplete or misleading information may be subject to civil or criminal penalties, policy denial, and recovery of damages.

Applicant represents that all vehicles to be insured are owned by the applicant or are listed with the consent of the owner, and that any person who will operate the vehicle has a valid license for the class of vehicle to be operated.

Authorization Checkboxes

I authorize release of my motor vehicle record (MVR) to the insurer.    I authorize a credit-based insurance score inquiry where permitted.

I authorize inspection of the vehicle(s) by the insurer or its representative.

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