Insurance Service Center DePere - Motorcycle Insurance Checklist

Client Name

First NameLast Name

Email Address

Optional Coverages

Are you interested in...

Roadside Assistance on your policy or AAA Gold Membership

Towing and Labor

Accessory Coverage (saddlebags, etc)

If yes, indicate how much coverage you would want:

Coverage for Safety Riding Apparel (helmets, leathers, etc)

If yes, indicate how much coverage you would want:

After Factory Customization (chrome, special paint job)

If yes, indicate how much coverage you would want:

Coverage for a Transport Trailer

If yes, indicate how much coverage you would want:

Questions

Rows	Yes	No	Call Me
Are you interested in higher medical payments coverage, liability limits and/or an umbrella liability policy?
Are you a member of a riding club such as AMA, HOG, etc.
Are any of the cycles Custom or Vintage?
Have you taken a drivers safety course in the past 3 years?

Do you understand there is NO COVERAGE for:

Cycles and Drivers not listed on your policy
Cycle loans or leases
Cycles not titled in your name

*Coverage subject to policy limitations and payable in the event of qualified claims.

Comments

I have personally reviewed the answers above. I understand that this checklist is not meant to imply, in any manner, that these are the ONLY items that may be of concern to me. I understand it is my responsibility to advise Insurance Service Center of any special circumstances or insurance needs I may have.

Client Signature

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