Insurance Service Center DePere - Motorcycle Insurance Checklist

Client Name*

First NameLast Name

Email Address

Optional Coverages

Are you interested in...

Roadside Assistance on your policy or AAA Gold Membership*

YesNoCall Me

Towing and Labor*

YesNoCall Me

Accessory Coverage (saddlebags, etc)*

YesNoCall Me

If yes, indicate how much coverage you would want:

Coverage for Safety Riding Apparel (helmets, leathers, etc)*

YesNoCall Me

If yes, indicate how much coverage you would want:

After Factory Customization (chrome, special paint job)*

YesNoCall Me

If yes, indicate how much coverage you would want:

Coverage for a Transport Trailer*

YesNoCall Me

If yes, indicate how much coverage you would want:

Questions*

	Yes	No	Call Me
Are you interested in higher medical payments coverage, liability limits and/or an umbrella liability policy?
Are you a member of a riding club such as AMA, HOG, etc.
Are any of the cycles Custom or Vintage?
Have you taken a drivers safety course in the past 3 years?

Do you understand there is NO COVERAGE for:

Cycles and Drivers not listed on your policy
Cycle loans or leases
Cycles not titled in your name

Yes, I understand these things are not covered under my cycle policy.I have questions, please call me.

*Coverage subject to policy limitations and payable in the event of qualified claims.

Comments

I have personally reviewed the answers above. I understand that this checklist is not meant to imply, in any manner, that these are the ONLY items that may be of concern to me. I understand it is my responsibility to advise Insurance Service Center of any special circumstances or insurance needs I may have.

Client Signature*

Date*

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