Thurston Insurance

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On-Line Motorcycle Insurance Quote Form
Your Personal Data:
*Your Name
*Street Address
*City
*State
*Zip Code
*E-Mail
E-Mail (repeat)
*Phone
fax(optional)
 

Driver Information #1
*Name
*Birthdate
sex
*# Years US Auto License
*# Years US Cycle License
Cycle Safety Course?
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" (carriers require proof on NOT-at-fault accidents).
Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
*Number & Type of Accidents last 3 years (enter 0 if none)
*Number & Type of MINOR Accidents last 3 years (enter 0 if none)
*Number & Type of MAJOR Accidents last 3 years (enter 0 if none)
*Daily commute in ONE WAY miles
social security number (optional but needed for some companies to give price)
driver's license number (optional but needed for some companies to give price)
Does need an SR22 FILING
If yes to SR22, why needed?

Driver Information #2 (if none, leave blank)
Name
Birthdate
sex
# Years US Auto License
# Years US Cycle License
Cycle Safety Course?
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" (carriers require proof on NOT-at-fault accidents).
Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years (enter 0 if none)
Number & Type of MINOR Accidents last 3 years (enter 0 if none)
Number & Type of MAJOR Accidents last 3 years (enter 0 if none)
Daily commute in ONE WAY miles
social security number (optional but needed for some companies to give price)
driver's license number (optional but needed for some companies to give price)
Does need an SR22 FILING
If yes to SR22, why needed?

If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here

RV #1 Information
*Year of vehicle
*Make & Model
Is it a 4 Wheeler?
If yes, describe:
*Annual Mileage:
Number of CC's
Value of bike ($)
Value of special Equipment ($)
RV #1 Coverages
Limit of Liability
Comprehensive Coverage and collision
Uninsured Motorists coverage
Medical coverage

Motorcycle #2 Information (leave blank if not applicable)
Year of vehicle
Make & Model
Is it a 4 Wheeler?
If yes, describe:
Annual Mileage:
Number of CC's
Value of bike ($)
Value of special Equipment ($)
Motorcycle #2 Coverages
Limit of Liability
Comprehensive Coverage and collision
Uninsured Motorists coverage
Medical coverage

If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here

Comments or remarks
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