MOTORCYLES AND ATVS INSURANCE APPLICATION

Please print out fill out our Motorcycle and ATV application for Insurance and mail or bring it into our office. This will expedite your application process.

Driver Information
Last Name
Number of Drivers
Age
Sex	Male Female
Years of Experience*
Years Licensed
*Enter the number of years experience driving this type of vehicle for this driver.
Accidents/Violations (In last 40 months)	Number of at fault accidents
	Number of minor violations
	Number of major violations

Vehicle Information
Vehicle Type	Motorcycle ATV
Model Year
Purchase Price
Vehicle Use	Pleasure Business/Commercial Use Off Road Use Driving to & From Work
Vehicle Make	BMW Buell Harley Honda Kawasaki Suzuki Triumph Yamaha Other
Vehicle Model
Class	High Performance Touring Sport
C.C.Size
Number of Wheels	(two to eight wheels)
Is Vehicle Garaged?	Yes No
Chopped	Yes No
Altered	Yes No
Custom Built	Yes No
Assembled	Yes No
Additional Info. Garaging/Storage Zip Code

Coverages Requested
Liability Only	25 / 50 / 0 50 / 100 / 25 100 / 300 / 50
Uninsured Motorists	25 / 50 50 / 100 100 / 300
Comprehensive Deductible	250 500 1000
Collision Deductible	250 500 1000
Medical Payments	none 1000 2500 5000

Have you had an accident prevention course?	Yes No
Have you had an unfortunate situation made you filed with the state bankruptcy	Yes No
Number of Licensed operators in your household
How many years have you been licensed in New York?
How many years have you been licensed other than in New York?
Add-on Accessories Value
Safety Discounts	Yes No
MC- A Discount applies to all coverages if the highest rated operator has completed a motorcycle Safety Foundation Rider Course within the past three years.
Audible Anti-Theft	Yes No
A discount applies to all coverages if an applicant uses an audible alarm system

Select the Major Violations this driver has had in the past 35 months
	Age Unl Op-Inf
	Dangerous Driving w/BI-Death Acc.
	DR w/o Authority
	DR with wrong plate(s)
	Drag Racing
	Driving w/.10% alcohol level
	Driving While Impaired
	Driving While Suspended
	DUI-Drugs/Opiates
	Eluding an Officer
	Evading Prosecution
	Failed to Report Acc.
	Giving False Ins Claim / Doc w/DMV
	Hit Skip
	Holding more than 1 Lic-Inf
	Leaving the Scene INC
	Lic / Reg Obtained Unlawfully
	Motor Vehicle Felony
	Neg.Resulting in BI/Death
	Operating Vehicle in Vio Rest/Limit
	Permit Unlic Op Inf.
	Permit Unlic Op to Drive
	Reckless Resulting in BI/Death Acc
	Spd Resulting BI/Death Acc
	Speed Contest
	Unlic Chauffeur
	Unlic p-Glasses-Inf
	Unsupervised Learner
	Vehicular Homicide

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	All Speed
	Assured Clear Distance
	Backing Ctr access Hwy
	Backing Unsafely
	Cling to move Vehicle
	Coasting Gearing Neutral
	Cross Yellow Line
	Crossed Fire Hose
	Crossing Divided Hwy
	Dangerous Driving
	Dec Speed w/o Signal
	Disobey Green Arrow
	DR Across Hazard Mark
	DR in Center Lane
	DR in Commuter Lane
	DR Left No Passing Zone
	DR Left of Pave Mark
	DR Left on Bridge
	DR Left on Curve
	DR on Closed Hwy
	DR on Restricted St
	DR on Sidewalk
	DR over Dividing Space
	DR Thru Crossgate
	DR Thru Safety Zone
	Driver View Obstructed
	Driving Too Slow
	Drove Wrong Direction
	Earphone Violation
	Enter Ext Ctr Ac Hwy
	Excess Passenger on MC
	Failed to allow Suff. Space
	Failed to Comply With Order
	Failed to Give 1/2 of Lane
	Failed to Keep Right
	Failed to Keep Right - Slow Veh.
	Failed to Keep School Bus Halted
	Failed to Turn as Required
	Failed to Use Designated Lane
	Failure to Use Due Care
	Failure to Yield
	Follow Too Close
	Improper Left Turn - 1 way
	Improper op / Careless
	Improper Passing
	Improper Prohibited Turn
	Inadequate Brakes
	Interfered w/fire apparatus
	Interfered w/safe op.
	Left Around Traf Ild
	Left of Center
	Limited use Vehicle Viol.
	Logs Insecure Fasten
	Miscellaneous Vio.
	More than three in front
	Moved from lane Unsafely
	MTC Between Lanes
	MTC More Than two Abreast
	No Safety Chain
	No Trap on Truck
	Obstruct Intersection
	Passed Red Light
	Permit Clinking to MV
	Prohibited U-Turn
	Reckless No Acc or Pd Acc
	Slow Speed / Drive too Slow
	Speed 15 MPH or Less
	Speed Not Reasonable for Conditions
	Speed Not Reasonable / prudent
	Stop Sign
	Stop without signaling
	Stopped School Bus
	Stopping on Parkway
	Traffic Cont Dev/Signs
	Trv Ln Ctr Red Sig
	Turn Signals
	Unauthorized Towing
	Unsafe Operation
	Unsafe Start / Backing
	Veh Not Under Control
	Vio 1 Way Traffic
	Vio Basic Rule
	Vio Railroad Crossing
	Vio Starting / Backing
	Vio to Avoid Light / Intersection
	Vio Traf Lanes / Lines
	Vio Turn Signals
	Vio When Being Passed
	Wrong Direction
	Wrong Side of Road

On Policies With Physical Damage, coverage is only provided for factory Standard Equipment.

The following is a list of items that would require Accessories/ Add on Equipment Coverage:

Chrome Parts, Custom Paint Jobs, Trailers, Sidecars, Saddle Bags, Fairings and other accessories that are not factory standard.

The items that are not eligible as Add on equipment.

Helmets, Headsets / Intercom Systems, Radar Detectors, Any Clothing Apparel.

If any ACV exceeds $5000, an inventory and photos must be submitted. A $100 deductible will apply.

ALL FORMS OF INSURANCE

286 NO. FRANKLIN ST. HEMPSTEAD NY 11550

GARY BENNETT

PHONE: 516-483-2814

FAX: 516-483-5218