Motorcycle Insurance Worksheet
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1
2MOTORCYCLE INSURANCE WORKSHEET
THIS IS NOT AN APPLICATION!
Agent Certification
Thum Insurance Agency, L.L.C.
Producer Name: ____________________________________________
3140 3 Mile Rd NE
Address: _________________________________________________
Grand Rapids, MI 49525-3165
800-866-0777
Fax: 616-957-1204
_________________________________________________
Contact: ________________________ Agency Code: ______________
Call or fax this worksheet for a proposal. Call to bind coverage.
Phone Number: __________________ Fax: ______________________
This is simply a worksheet to gather information for a quotation.
Registration State & Zip Code: ____________________
Applicant:
First Name: __________________________ M.I. _______ Last Name __________________________________ Phone: _____________________________
Co-Applicant:
First Name: __________________________ M.I. _______ Last Name __________________________________ Phone: _____________________________
Is Co-Applicant living in same Household? [ ] Yes
[ ] No – explain relation ________________________________________
Mailing Address: _____________________________________________________________ City: _________________________ State: _______ Zip: __________
Principal Garaging/Storage
Location: (if not same as mailing) ________________________________________________ City: __________________________ State: _______ Zip: _________
Registration
Address: ___________________________________________________________________City: __________________________ State: _______ Zip: _________
Driver Information
(complete for all drivers)
# of all violations
# of years
in the past
Birth Date
Marital
Driver’s License #
Social
operating
36 Months
Name
Mo./Day/Yr.
Sex
Status
(Valid U.S. or Canadian)
ST
Security #
MCs
At-fault ] Minor ] Major
[] M
[] S
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[] M
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[] S
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[] M
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List Violations on Page 2
Vehicle Information
Year
Make / Model
CC Size
Vehicle ID #
Current Value
Purchase Price
$
$
Year
Make / Model
CC Size
Vehicle ID #
Current Value
Purchase Price
$
$
Custom Parts and Equipment
Describe additional custom parts and equipment:
Total Value CPE: $ _____________
*Pictures required to ISSUE custom motorcycle policies
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Parent category: Legal