GoldenRuleInsurance.com -Cycle & 4-Wheeler Quote Page

On-Line Motorcycle & 4 Wheeler Insurance Quote Form

Your Personal Data
Your Name:
Street Address:
City:
*State:
Zip Code:
E-Mail (REQUIRED):
Confirm E-Mail:
Phone:
Fax (optional):

Marital Status: Single Married	Homeowner? Yes No

Currently Insured? (If yes, list carrier, and # of years continuous. If none, type NONE)

DRIVER INFORMATION #1
Name:		Birthdate:

Sex (M/F):		# 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 Cites within last 3 years:

Number & Type of MAJOR Cites within last 3 years:		Daily commute in ONE WAY miles:

Does Driver a SR-22 FILING?	Yes No	Comments or Remarks?


DRIVER INFORMATION #2
Name:		Birthdate:

Sex (M/F):		# 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 Cites within last 3 years:

Number & Type of MAJOR Cites within last 3 years:		Daily commute in ONE WAY miles:

Does Driver a SR-22 FILING?	Yes No	Comments or Remarks?


VEHICLE #1 INFORMATION
Year of vehicle:		Make & Model:

Is this a 4 Wheeler?:		If Yes, Describe:

Annual Mileage:		# of CC's:

Value of Bike:	$	Special Equipment Value:	$

VEHICLE #1 COVERAGES:
Limits of Liability:	$25/50 BI / 25 PD $50/100 BI / 50 PD $100/300 BI / $100 PD $250/500 BI / 100 PD

Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Do you want Medical Coverage?	Yes No	Uninsured Motorists Coverage?	Yes No

VEHICLE #2 INFORMATION(if None, leave it blank.)
Year of vehicle:		Make & Model:

Is this a 4 Wheeler?:		If Yes, Describe:

Annual Mileage:		# of CC's:

Value of Bike:	$	Special Equipment Value:	$

VEHICLE #2 COVERAGES:
Limits of Liability:	$25/50 BI / 25 PD $50/100 BI / 50 PD $100/300 BI / $100 PD $250/500 BI / 100 PD

Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Do you want Medical Coverage?	Yes No	Uninsured Motorists Coverage?	Yes No

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

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a Cycle Quote NOW! *Hawkins Insurance Group is licensed to sell in more than 20 states. If you are contacting us from a state in which we are not licensed, we will contact you to inform you that we cannot provide you with a quote.

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