Motorcycle Insurance Worksheet Page 2
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2Coverages Worksheet
Motorcycle –
[ ]
Full Package
BI/PD & UM/UIM BI/PD and basic medical only
Base Limits
[ ]
Full Package Includes the following:
$100,000/$300,000 BI (Guest passenger coverage Included)
Comprehensive less $500 deductible
$100,000/$300,000 UM/UIM BI
Collision less $500 deductible
Basic PIP / Medical payments
Roadside assistance coverage
OPTIONAL LIMITS
– for all age & marital status groups
Deductibles
Medical Payments (per person)
Comprehensive [ ] $100 [ ] $250 [ ] $1,000
Collision
[ ] $100 [ ] $250 [ ] $1,000
[ ] $1,000
[ ] $2,500
* Bodily Injury & Property Damage (guest passenger coverage included)
[ ] $5,000
[ ] $10,000
[ ] $50,000/$100,000
[ ] $250,000/$500,000
[ ] $300,000 combined single limit
[ ] $500,000 combined single limit
[ ] Other ____________________
* UM/UIM Bodily Injury
[ ] $50,000/$100,000
[ ] $250,000/$500,000
[ ] $300,000 combined single limit
[ ] $500,000 combined single limit
[ ] Other ____________________
Additional Coverages
Custom Parts & Equipment: Included $1,000
[ ] Additional amount desired _____________ (round to the nearest thousand)
[ ] Agreed Value Coverage (only available on certain models & years)
–
Discounts
Discounts may not be applicable in all states. Proof of applicable documentation will be required.
Current Homeowner? _____________ (proof required) Current Insurance on MC? _________________ (Proof required)
Underwriting Questions
Yes No
8. Please list an explanation of all accidents and violation within the past
1. Is the motorcycle the only motorized vehicle in the household?
[ ]
[ ]
three years.
2. Do you currently own or rent a home?
[ ]
[ ]
3. Do you currently have a Homeowners/Tenant Policy?
[ ]
[ ]
4. Is or will the unit be rented or leased?
[ ]
[ ]
5. Is or will the unit be used strictly for pleasure?
[ ]
[ ]
The undersigned hereby warrants and certifies that all information contained herein
6
Is or will the unit be used in connection with any operators business
.
is correct to the best of my knowledge and that this form was completed and
or profession?
[ ]
[ ]
signed by the Producing Agent.
7. What is the estimated annual mileage? _____________________
Producing Agent Signature X ___________________________Date __________
THIS IS ONLY A WORKSHEET NOT AN APPLICATION
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