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Motorcycle and Off Road Vehicle Insurance Quote Request
 
Click here for a printable form

 
Customer Information
First Name:  
Middle Name:  
Last Name:  
Sex:   M  F

Date of Birth:

 
Social Security Number:  
     
Phone Number:  
Home Address:  
City, State, Zip Code:  
Marital Status:  

Married   Single   Other
Email Address:  
Primary Residence:   Own Home/ Condo
    Own Mobile Home: 10 years old or newer
    Rent
    Live with Parents
    Other
     
Driving Record (prior 35 months)    

Number of/ Nature of Tickets (all vehicles)

  
Number of/ Nature of AF/ NAF Auto/ Motorcycle Accidents:  
Automobile Driver License Status:  
Motorcycle / Off – Road Information
Year:  
Make:  
Model:  
CC Size:  
Is the Motorcycle a Trike?   Yes  No
VIN:  
Special Hazard (Turbo or nitrous oxide kit modified frame?)   Yes  No
     
Special Construction Determination    
Does the vehicle fall into one of the following categories?    
(If so, Physical Damage coverage not available.)   Homemade or Composite
    Kit
    State-Assigned VIN
    Non-factory built MC/ Trike
    Not listed in both Kelley Blue Book or N.A.D.A. Appraisal Guide
    Original frame has been replaced
Underwriting Information
Garaging ZIP Code  
Passed Safety Course   Yes  No

Vehicle Use (i.e. Pleasure, business, etc.):

   Pleasure
    Business
    Off-Road
Other Policies (5% Discount):   Automobile
    Boat/ PWC
    Motorcycle/ ATV/ Snowmobile
    RV
Names of Regular Operators (Any operator with regular access to insured vehicle more than 12 times a year):  

Names of Household Resident Operators:

  
Coverage Information
Liability / Guest Passenger Limits:  
UM/ UIM:  
UMPD:  
Med Pay:  
Comp / Collision Deductibles:  
Roadside Assistance:  
Transport Trailer:  
     
Accessory Coverage    
Paint:   $
Chrome:   $
Wheels:   $
Trike Kit:   $
Saddlebags / Windshield:   $
Pull Behind Trailer:   $

Other:

   $
Total:   $
 
 

 
 

Haley Insurance Agency

P.O. Box 8787 - The Woodlands TX, 77387

Phone: 281-364-7888  -  Toll Free: 1-888-4 BIKERS  -  Fax: 281-367-1127

Email: info@haleyinsuranceonline.com

Webmaster: Texas Marketing Group