Number & Type of MINOR violations
within last 3 years:
Number & Type of MAJOR violations
within last 3 years:
# years U.S. cycle license:
Does
Driver need an SR22 FILING?
Yes No
Comments or Remarks?
DRIVER
INFORMATION #2 (if none, leave
blank)
Name:
Birthdate:
Sex:
Minnesota Drivers License #:
Cycle Safety Course?
Social Security #:
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:
# years U.S. cycle license:
Does
Driver need an SR22 FILING?
Yes No
Comments or Remarks?
VEHICLE #1
INFORMATION
Year
of vehicle:
Make
& Model:
Is
this a ATV or 4 Wheeler?:
If
Yes, Describe:
Annual Mileage:
# of
CC's:
Value of Bike:
$
Special Equipment Value:
$
VEHICLE #1
COVERAGES:
Limits of Liability:
$30/60 BI / 10 PD $50/100 BI / 25 PD $100/300 BI / 50 PD $250/500 BI / 100 PD
Comprehensive &
Collision:
NO Coverage $250
Deductible $500
Deductible $1000 Deductible
Do
you want Medical Coverage?
Yes No
Uninsured & Underinsured Motorists
Cov.?
Yes
No
VEHICLE #2
INFORMATION (if none, leave blank)
Year
of vehicle:
Make
& Model:
Is
this a ATV or 4 Wheeler?:
If
Yes, Describe:
Annual Mileage:
# of
CC's:
Value of Bike:
$
Special Equipment Value:
$
VEHICLE #2
COVERAGES:
Limits of Liability:
$30/60 BI / 10 PD $50/100 BI / 25 PD $100/300 BI / 50 PD $250/500 BI / 100 PD
Comprehensive &
Collision:
NO Coverage $250
Deductible $500
Deductible $1000 Deductible
Do
you want Medical Coverage?
Yes No
Uninsured & Underinsured Motorists
Cov.?
Yes
No
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