Employment Opportunities with Haines & Haines/T.C. Irons

Motorcycle Insurance Quotation Form

GENERAL INFORMATION
Street Address
City
State	New York ONLY!
Zip Code
Marital Status Single Married	Is Spouse Vehicle Operator? Yes No N/A
Homeowner?	Yes No
Currently Insured? Yes No	(If YES, list current company below)
If Not Currently Insured When did Coverage End?	N/A 0-30 Days 31 Days or More
Are You a member of a Motorcycle Group? Yes No	(If yes, list Motorcycle Group below i.e. HOG, Cycle USA, Etc.)
Have you Attended a Motorcycle Safety Course? Yes No	(If yes, list Motorcycle Course Date below)
Have you Attended an Automobile Defensive Driving Course? Yes No	(If yes, list Auto Defensive Driving Date below)
CURRENT MOTORCYCLE COVERAGE Liability Limits	$25k/50k $50k/100k $100k/300k $250k/500k None

DRIVER INFORMATION
Name		Birth date
Sex (M/F)		# Yrs U.S. Cycle  Licensing
		# Yrs Total Cycle  Experience
In order to obtain all available DISCOUNTS, carriers run a low level insurance credit check. By providing Social Security # and Driver's License #, we can obtain the LOWEST RATE AVAILABLE!
Driver 1 Social Security #		Driver 1 Driver's License #
- IMPORTANT INFORMATION - To receive an accurate quote, you must provide information regarding the approx. DATE and TYPE of any CLAIMS or TRAFFIC VIOLATIONS within the last 39 MONTHS.
DATE	CLAIM / TRAFFIC VIOLATION TYPE
	SELECT ******SELECT CLAIM TYPE******* At Fault Accident $1,000 or less in damage and no Bodily Injury At Fault Accident/Accident with Bodily Injury $1001 or over Comprehensive Claim $1,000 or Less Comprehensive Claim Over $1,000 Not at Fault Accident *****SELECT VIOLATION TYPE***** Accident Prevention Course Auto Theft/Felony Motor Vehicle Commercial Vehicle Violation Defective Equipment Drag Racing Drive Under Influence/Drive While Intoxicated Driving Under Suspension Failure to Report Accident Failure to Yield False Reporting Fleeing From Police Following Too Close Improper Backing Improper Passing Improper Turn Leaving the Scene License/Credentials Violation Minor Moving Violation No Valid License Open Bottle Operating Without License/Invalid Registration Other Serious Violation Passing a School Bus Permit Unlicensed Operator to Drive Reckless Driving Speeding 15 MPH or Less Speeding 16 MPH or More Speeding With Injury Traffic Device or Sign Vehicular Homicide Without Owner's Consent Wrong Way on a One-Way Street
	SELECT ******SELECT CLAIM TYPE******* At Fault Accident $1,000 or less in damage and no Bodily Injury At Fault Accident/Accident with Bodily Injury $1001 or over Comprehensive Claim $1,000 or Less Comprehensive Claim Over $1,000 Not at Fault Accident *****SELECT VIOLATION TYPE***** Accident Prevention Course Auto Theft/Felony Motor Vehicle Commercial Vehicle Violation Defective Equipment Drag Racing Drive Under Influence/Drive While Intoxicated Driving Under Suspension Failure to Report Accident Failure to Yield False Reporting Fleeing From Police Following Too Close Improper Backing Improper Passing Improper Turn Leaving the Scene License/Credentials Violation Minor Moving Violation No Valid License Open Bottle Operating Without License/Invalid Registration Other Serious Violation Passing a School Bus Permit Unlicensed Operator to Drive Reckless Driving Speeding 15 MPH or Less Speeding 16 MPH or More Speeding With Injury Traffic Device or Sign Vehicular Homicide Without Owner's Consent Wrong Way on a One-Way Street
	SELECT ******SELECT CLAIM TYPE******* At Fault Accident $1,000 or less in damage and no Bodily Injury At Fault Accident/Accident with Bodily Injury $1001 or over Comprehensive Claim $1,000 or Less Comprehensive Claim Over $1,000 Not at Fault Accident *****SELECT VIOLATION TYPE***** Accident Prevention Course Auto Theft/Felony Motor Vehicle Commercial Vehicle Violation Defective Equipment Drag Racing Drive Under Influence/Drive While Intoxicated Driving Under Suspension Failure to Report Accident Failure to Yield False Reporting Fleeing From Police Following Too Close Improper Backing Improper Passing Improper Turn Leaving the Scene License/Credentials Violation Minor Moving Violation No Valid License Open Bottle Operating Without License/Invalid Registration Other Serious Violation Passing a School Bus Permit Unlicensed Operator to Drive Reckless Driving Speeding 15 MPH or Less Speeding 16 MPH or More Speeding With Injury Traffic Device or Sign Vehicular Homicide Without Owner's Consent Wrong Way on a One-Way Street
	SELECT ******SELECT CLAIM TYPE******* At Fault Accident $1,000 or less in damage and no Bodily Injury At Fault Accident/Accident with Bodily Injury $1001 or over Comprehensive Claim $1,000 or Less Comprehensive Claim Over $1,000 Not at Fault Accident *****SELECT VIOLATION TYPE***** Accident Prevention Course Auto Theft/Felony Motor Vehicle Commercial Vehicle Violation Defective Equipment Drag Racing Drive Under Influence/Drive While Intoxicated Driving Under Suspension Failure to Report Accident Failure to Yield False Reporting Fleeing From Police Following Too Close Improper Backing Improper Passing Improper Turn Leaving the Scene License/Credentials Violation Minor Moving Violation No Valid License Open Bottle Operating Without License/Invalid Registration Other Serious Violation Passing a School Bus Permit Unlicensed Operator to Drive Reckless Driving Speeding 15 MPH or Less Speeding 16 MPH or More Speeding With Injury Traffic Device or Sign Vehicular Homicide Without Owner's Consent Wrong Way on a One-Way Street
	SELECT ******SELECT CLAIM TYPE******* At Fault Accident $1,000 or less in damage and no Bodily Injury At Fault Accident/Accident with Bodily Injury $1001 or over Comprehensive Claim $1,000 or Less Comprehensive Claim Over $1,000 Not at Fault Accident *****SELECT VIOLATION TYPE***** Accident Prevention Course Auto Theft/Felony Motor Vehicle Commercial Vehicle Violation Defective Equipment Drag Racing Drive Under Influence/Drive While Intoxicated Driving Under Suspension Failure to Report Accident Failure to Yield False Reporting Fleeing From Police Following Too Close Improper Backing Improper Passing Improper Turn Leaving the Scene License/Credentials Violation Minor Moving Violation No Valid License Open Bottle Operating Without License/Invalid Registration Other Serious Violation Passing a School Bus Permit Unlicensed Operator to Drive Reckless Driving Speeding 15 MPH or Less Speeding 16 MPH or More Speeding With Injury Traffic Device or Sign Vehicular Homicide Without Owner's Consent Wrong Way on a One-Way Street
	SELECT ******SELECT CLAIM TYPE******* At Fault Accident $1,000 or less in damage and no Bodily Injury At Fault Accident/Accident with Bodily Injury $1001 or over Comprehensive Claim $1,000 or Less Comprehensive Claim Over $1,000 Not at Fault Accident *****SELECT VIOLATION TYPE***** Accident Prevention Course Auto Theft/Felony Motor Vehicle Commercial Vehicle Violation Defective Equipment Drag Racing Drive Under Influence/Drive While Intoxicated Driving Under Suspension Failure to Report Accident Failure to Yield False Reporting Fleeing From Police Following Too Close Improper Backing Improper Passing Improper Turn Leaving the Scene License/Credentials Violation Minor Moving Violation No Valid License Open Bottle Operating Without License/Invalid Registration Other Serious Violation Passing a School Bus Permit Unlicensed Operator to Drive Reckless Driving Speeding 15 MPH or Less Speeding 16 MPH or More Speeding With Injury Traffic Device or Sign Vehicular Homicide Without Owner's Consent Wrong Way on a One-Way Street
	SELECT ******SELECT CLAIM TYPE******* At Fault Accident $1,000 or less in damage and no Bodily Injury At Fault Accident/Accident with Bodily Injury $1001 or over Comprehensive Claim $1,000 or Less Comprehensive Claim Over $1,000 Not at Fault Accident *****SELECT VIOLATION TYPE***** Accident Prevention Course Auto Theft/Felony Motor Vehicle Commercial Vehicle Violation Defective Equipment Drag Racing Drive Under Influence/Drive While Intoxicated Driving Under Suspension Failure to Report Accident Failure to Yield False Reporting Fleeing From Police Following Too Close Improper Backing Improper Passing Improper Turn Leaving the Scene License/Credentials Violation Minor Moving Violation No Valid License Open Bottle Operating Without License/Invalid Registration Other Serious Violation Passing a School Bus Permit Unlicensed Operator to Drive Reckless Driving Speeding 15 MPH or Less Speeding 16 MPH or More Speeding With Injury Traffic Device or Sign Vehicular Homicide Without Owner's Consent Wrong Way on a One-Way Street
	SELECT ******SELECT CLAIM TYPE******* At Fault Accident $1,000 or less in damage and no Bodily Injury At Fault Accident/Accident with Bodily Injury $1001 or over Comprehensive Claim $1,000 or Less Comprehensive Claim Over $1,000 Not at Fault Accident *****SELECT VIOLATION TYPE***** Accident Prevention Course Auto Theft/Felony Motor Vehicle Commercial Vehicle Violation Defective Equipment Drag Racing Drive Under Influence/Drive While Intoxicated Driving Under Suspension Failure to Report Accident Failure to Yield False Reporting Fleeing From Police Following Too Close Improper Backing Improper Passing Improper Turn Leaving the Scene License/Credentials Violation Minor Moving Violation No Valid License Open Bottle Operating Without License/Invalid Registration Other Serious Violation Passing a School Bus Permit Unlicensed Operator to Drive Reckless Driving Speeding 15 MPH or Less Speeding 16 MPH or More Speeding With Injury Traffic Device or Sign Vehicular Homicide Without Owner's Consent Wrong Way on a One-Way Street

 

VEHICLE INFORMATION
Year of vehicle
Make:
Model:
Annual Mileage		Used in business? (Explain, if yes)
CC's		Miles Driven to Work?
Alarmed?	Y N	Garaged?	Y N
Current Motorcycle Value
Motorcycle Accessories Value
REQUESTED VEHICLE COVERAGES
MANDATORY COVERAGE  Please Select One Option: (25/50/10 is the minimum allowed by law)
BI/GP - PD (See Definitions)	25 / 50 / 10    100 / 300 / 50 50 / 100 / 25  250 / 500 / 100
For  FULL COVERAGE  Please Select a Deduct able Below
Comprehensive & Collision	NO Coverage $250 Deductible $500 Deductible $1000 Deductible
Comments or Remarks:

 

CONTACT INFORMATION
First Name Last Name Email Phone                        Fax    Questions / Comments / Notes
Send my quotation via	E-Mail Fax Regular Mail Call me by Phone!
All quotes are based on the information that the applicant  provides, and are subject to change based on final underwriting by the  individual carriers.

 

 

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Privacy Policy-We routinely collect personal and/or business information that is needed as part of the quoting and underwriting process.  We also collect the same information as part of service and update activities.  The Haines & Haines/T.C. Irons Agency will not share that information, or use it in any other way, with outside parties, vendors, etc.

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