Name:
Street Address:
City:
County:
State:
Zip Code:
Home Phone:
Email:
Primary Driver:	Male Female
Marital Status:	Single Married Other
Date of Birth:	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Years Licensed (motorcycle):
Are you a homeowner?	Yes No
Spouse/Second Driver's Name:	Male Female
Second Driver's Date of Birth:	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Years Licensed:
Motorcycle safety courses taken: None Primary Driver 2nd Driver
Motorcycle association memberships:
Do any of the drivers listed require SR-22 filing? Yes No
If yes, which drivers? Primary 2nd Driver
Please explain which state requires this filing:
Have any of the drivers listed ever had a license suspended/revoked? Yes No
If yes, please provide name, date, and reason:
Please list any tickets/accidents for the past 3 years, and which drivers were involved.
Has the primary driver been insured within the past 30 days? Yes No
If yes, provide the name of the insurance company:
This policy expired/expires: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Please provide the following motorcycle information.
Year: Make (Suzuki): Model (Katana):
Engine size CC's: Number of wheels:
Days driven in 1 week: Estimated annual mileage:
Most used by: Select Primary Driver 2
Is motorcycle equipped with an audible antitheft device? Yes No
Locked in a garage or secured to a permanent structure? Yes No
Describe any modifications:
If modified, please provide value (NOT the total value of cycle):
Year: Make (Suzuki): Model (Katana):
Engine size Cc's: Number of wheels:
Days driven in 1 week: Estimated annual mileage:
Most used by: Select Primary Driver 2
Is motorcycle equipped with an audible antitheft device? Yes No
Locked in a garage or secured to a permanent structure? Yes No
Describe any modifications:
If modified, please provide value (NOT the total value of cycle):
Please select the type of coverage you desire (see explanation of coverage for more info).
Limits of liability (select one): 15/30/10 25/50/25 50/100/50
Comprehensive and collision on: Motorcycle 1 Motorcycle 2
Comprehensive and collision deductible (select one): 250 500
Uninsured/underinsured motorist coverage (required in SC): Yes No
For SC residents - passenger liability coverage? Yes No
For GA residents - medical payment (MED PAY) coverage? Yes No
Please mention any affiliated rider groups, and/or additional comments or concerns:
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