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On-Line Motorcycle
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


YOUR PERSONAL DATA:

Your Name:
Street Address:
City:
State: (Must be New Jersey)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
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 violations within
last 3 years:
Number & Type of
MAJOR violations within
last 3 years:
Daily commute
in ONE WAY miles:
Are you a member of a Cycle Club (HOG, BMW, etc.)? 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 violations within
last 3 years:
Number & Type of
MAJOR violations within
last 3 years:
Daily commute
in ONE WAY miles:
Are you a member of a Cycle Club (HOG, BMW, etc.)? Yes No Comments or
Remarks?


VEHICLE #1 INFORMATION
Year of vehicle: Make & Model:
Vin # Required by Carriers for Rating Accuracy:
Is this a 4 Wheeler?: If Yes, Describe:
Annual Mileage: # of CC's:
Value of Bike: $ Special Equipment Value: $
VEHICLE #1 COVERAGES:
Select Liability Limits
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?
Yes No   
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Vin # Required by Carriers for Rating Accuracy:
Is this a 4 Wheeler?: If Yes, Describe:
Annual Mileage: # of CC's:
Value of Bike: $ Special Equipment Value: $
VEHICLE #2 COVERAGES:
Select Liability Limits
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?
Yes No   


Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone



 
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BEST RATE AUTO INSURANCE, INC.
HEADQUARTERS: 2340 Whitney Avenue, 1st Floor, Hamden, CT 06518
Monday - Friday: 9am - 6:15pm | Saturday: 9am - 1pm | Sunday: Closed
Local Phone: 203-287-8411 | Toll Free: 1-888-299-7164
EMAIL: rybicki.vesna@yahoo.com


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