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First Name * Last Name * Gender * (select) Male Female Mailing Address * City * State * Zip Code * County * (select) Adams Asotin Benton Chelan Clallam Clark Columbia Cowlitz Douglas Ferry Franklin Garfield Grant Grays Harbor Island Jefferson King Kitsap Kittitas Klickitat Lewis Lincoln Mason Okanogan Pacific Pend Oreille Pierce San Juan Skagit Skamania Snohomish Spokane Stevens Thurston Wahkiakum Walla Walla Whatcom Whitman Yakima Phone Number * Email Address * Date of Birth * Marital Status * (select) Single Married Separated Divorced Widowed Residence Type * (select) Home (owned) Condo (owned) Apartment Rental Home/Condo Mobile Home Other Number of Years Motorcycle Experience * Motorcycle Endorsement * (select) Yes No Motorcycle Safety Foundation (MSF) Course * (select) Yes No If Yes, Date (MSF) Course Completed Motorcycle Association Membership (select) None AMA ABATE BMWMOA BRAG CMA GWRA GWTA HOG HRC MGNOC MSF RAT WOW Other-Not on List Number of Minor Moving Violations in Last 3 Years * Number of Major Moving Violations in Last 3 Years * Number of At-Fault Accidents in Last 3 Years * Number of Not-At-Fault Accidents in Last 3 Years * Number of Comprehensive Claims in Last 3 Years * Rider (2) First Name Rider (2) Last Name Rider (2) Gender (select) Female Male Relationship to Insured (select) Spouse Child Parent Other Rider (2) Date of Birth Rider (2) Years Motorcycle Experience Rider (2) MSF Course (select) Yes No Rider (2) - If Yes, Date MSF Course Completed Rider (2) - Number of Minor Moving Violations Rider (2) - Number of Major Moving Violations Rider (2) - Number of At-Fault Accidents Rider (2) - Number of Not-At-Fault Accidents Rider (2) - Number of Comprehensive Claims Motorcycle Year * Motorcycle Make * Motorcycle Model * Motorcycle Displacement (CC's) * Motorcycle Estimated Value * Motorcycle Financed (Lien Holder) * (select) Yes No Motorcycle Kept in Lockable Structure * (select) Yes No Motorcycle Use * (select) Pleasure Commute - Work/School Other Motorcycle (2) Year Motorcycle (2) Make Motorcycle (2) Model Motorcycle (2) Use (select) Pleasure Commute - Work/School Other Motorcycle (2) Displacement (CC's) Motorcycle (2) Estimated Value Motorcycle (2) Financed (Lien Holder) (select) Yes No Motorcycle (2) Kept in Lockable Structure (select) Yes No Liability Coverage * (select) 25/50/10 50/100/25 100/300/50 250/500/100 Underinsured Motorist Bodily Injury * (select) 25/50 50/100 100/300 250/500 REJECT Underinsured Motorist Property Damage * (select) 10,000 25,000 50,000 100,000 REJECT Comprehensive * (select) 100 Deductible 250 Deductible 500 Deductible 1000 Deductible NO COVERAGE Collision * (select) 100 Deductible 250 Deductible 500 Deductible 1000 Deductible NO COVERAGE Medical Payment * (select) None 1000 2000 5000 Towing & Roadside Assistance * (select) Yes No Current Motorcycle Insurance * (select) Yes No Current Carrier (select) Allstate American Family Dairyland Foremost GMAC Geico Markel Nationwide Progressive Safeco State Farm USAA Other - Not on List Expiration Date of Current Policy Additional Information