Brownell Advantage Motorcycle Quote Form
* Required Information
Company Name *
How long worked there? *
Full Name *
Address
City
State
Zipcode
Day Phone *
Cell Phone
Email *
Personal Information
Total number of Motorcycles, ATVs, Segways and Golf Carts you would like to include in this quote:
One
Two
Three
(If more than three vehicles, please call us at: 603-437-1992 to obtain a quote.)
Enter the total amount of operators that are Owners:
Enter the total amount of operators that are Household Residents:
Enter the total amount of operators that are Regular Non-resident users:
(If more than five operators, please call us at: 603-437-1992 to obtain a quote.)
What insurance company do you currently have a motorcycle policy with?
Has your USA address changed within the last 60 days?
Yes
No
Email Address: (Address that will be used to send your rate information.)
Driver #1 Information
Driver 1 Full Name
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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Year
2009
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1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Does driver require an SR-22 filing?
Yes
No
Status of Driver's license:
State licensed in
Primary Address:
City:
State:
Zipcode:
Phone:
Driver #2 Information
Driver 2 Full Name
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
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11
12
13
14
15
16
17
18
19
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23
24
25
26
27
28
29
30
31
Year
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
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1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Does driver require an SR-22 filing?
Yes
No
Status of Driver's License
State licensed in
Primary Address:
City:
State:
Zipcode:
Phone:
Driver #3 Information
Driver 3 Full Name
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Does driver require an SR-22 filing?
Yes
No
Status of Driver's License:
State licensed in
Primary Address:
City:
State:
Zipcode:
Phone:
Accidents/Violations Information
Driver 1 Violations:
Driver 2 Violations:
Driver 3 Violations:
Vehicle #1 Information
Vehicle Type:
Motorcycle
ATV
Segway
Golf Cart
Other
If other please explain:
VIN Number:
Model Year: (for Segway, enter year manufactured)
Manufacturer:
Model:
Vehicle Modification:
Vehicle Ownership:
Zipcode for primary location of your vehicle:
Engine CCs: (cubic centimeter size - enter '0' for electric bikes)
Is your Motorcycle a Trike?
Yes
No
Vehicle use:
Pleasure
Work
Business
If work, number of miles each way:
Vehicle #2 Information
Vehicle type:
Motorcycle
ATV
Segway
Golf Cart
Other
If other please explain:
VIN Number:
Model Year: (for Segway, enter year manufactured)
Manufacturer:
Model:
Vehicle Modification:
Vehicle Ownership:
Zipcode for primary location of your vehicle:
Engine CCs: (cubic centimeter size - enter '0' for electric bikes)
Is your Motorcycle a Trike?
Yes
No
Vehicle use:
Personal
Work
Business
If work, number of miles each way:
Vehicle #3 Information
Vehicle type:
Motorcycle
ATV
Segway
Golf Cart
Other
If other please explain:
VIN Number:
Model Year: (for Segway, enter year manufactured)
Manufacturer:
Model:
Vehicle Modification:
Vehicle Ownership:
Zipcode for primary location of your vehicle:
Engine CCs: (cubic centimeter size - enter '0' for electric bikes)
Is your Motorcycle a Trike?
Yes
No
Vehicle use:
Pleasure
Work
Business
If work, number of miles each way:
Policy Coverages
Bodily Injury & Property Damage:
25,000/50,000
50,000/100,000
250,000/500,000
Uninsured Motorist Bodily Injury:
25,000/50,000
50,000/100,000
250,000/500,000
Medical Payments
5,000
10,000
Transport trailer: (Enter the value of your transport trailer, one trailer per policy, requires Comprehensive and Collision on at least one vehicle)
Comprehensive Deductibles:
100
250
500
1000
Collision Deductibles:
250
500
1000
Roadside Assistance: (requires Comprehensive coverage)
Custom Parts and Equipment Value: (requires Comprehensive coverage)
Fill in text as it appears in box to right *