Steve
Stephen B. Groton -- Insurance Agent and Broker
CA License Number 0816642
626-584-6303

Motorcycle Insurance
Quote Form
One Simple Form - takes only a few minutes!
YOUR PERSONAL DATA:
Your Name:
Street Address:
City:
State: MUST be California!
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
Marital Status:
 Single Married
Homeowner?
 Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If no, type NONE)
 
DRIVER INFORMATION #1
Name: Birthdate:
Sex: # Years U.S.
 Auto License:
Cycle Safety Course? # Years U.S.
 Cycle License:
Number & Type of
Accidents within
last 3 years:		 Number & Type of
MINOR Cites within
last 3 years:
Number & Type of
MAJOR Cites within
last 3 years:		 Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?		 Yes No Comments or
Remarks?
 
DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Auto License:
Cycle Safety Course? # Years U.S.
 Cycle License:
Number & Type of
Accidents within
last 3 years:		 Number & Type of
MINOR Cites within
last 3 years:
Number & Type of
MAJOR Cites within
last 3 years:		 Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?		 Yes No Comments or
Remarks?
VEHICLE #1 INFORMATION
Year of vehicle: Make & Model:
Is this a 4 Wheeler?: If Yes, Describe:
Annual Mileage: # of CC's:
Value of Bike: $ Special Equipment Value: $
VEHICLE #1 COVERAGES:
Limits of
Liability:		 $15/30 BI / 10 PD
$25/50 BI / 15 PD
$50/100 BI / 50 PD
$100/300 BI / 50 PD
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?		 Yes No   Uninsured
  Motorists Cov.?		 Yes No
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Is this a 4 Wheeler?: If Yes, Describe:
Annual Mileage: # of CC's:
Value of Bike: $ Special Equipment Value: $
VEHICLE #2 COVERAGES:
Limits of
Liability:		 $15/30 BI / 10 PD
$25/50 BI / 15 PD
$50/100 BI / 50 PD
$100/300 BI / 50 PD
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?		 Yes No   Uninsured
  Motorists Cov.?		 Yes No
Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone
Thank you for filling out this form COMPLETELY!

We respect your privacy! Every step has been taken to insure your privacy and security. It is our intent to release quote information only to you. We will not give your data to ANY other person, company, or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others.

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Motorcycle Quote NOW!

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