Name
Phone
6650 Reseda Blvd
Suite #108
Reseda, CA 91335
contact@gisinsure.com
Motorcycle
First Name:
Last Name:
Garaging Address:
Garaging City:
Garaging State:
Select...
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Utah
Virginia
Vermont
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Wisconsin
West Virginia
Wyoming
Garaging Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
Who Referred You:
Mailing Address (Optional)
Mailing Address
(If Different from Garaging):
Mailing City:
Mailing State:
Select...
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Mailing Zip Code:
Driver Information
Driver One
Driver Two
Driver Three
Driver Four
First Name
Birthdate
Sex
Male
Female
Male
Female
Male
Female
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Separated
Single
Married
Divorced
Widowed
Separated
Single
Married
Divorced
Widowed
Separated
Single
Married
Divorced
Widowed
Separated
Yrs Licensed
State Licensed
Occupation
Motorcycle Information
Motorcycle 1
Motorcycle 2
Motorcycle 3
Motorcycle 4
Year
Make
Model
Engine CC's
I.D. #
Miles Driven
Each Year
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Ownership
Leased
Paid-Off
Financed
Leased
Paid-Off
Financed
Leased
Paid-Off
Financed
Leased
Paid-Off
Financed
Violation Information
Last 3 Yrs (Minors)
Last 5 Yrs (Majors)
Driver 1
Driver 2
Driver 3
Driver 4
Minor Violations - Speeding,
Turn, Stop Sign, Red Light, etc.
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Accidents - Non Chargeable
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Accidents - Chargeable
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Major Violations - Drunk Driving,
Reckless, Hit & Run, etc.
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Coverage Information
Bodily Injury
Property Damage
Personal Liability
15,000/30,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
5,000
10,000
25,000
50,000
100,000
Uninsured Motorist
No Coverage
15,000/30,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
No Coverage
3,500
Deductible Waiver
Medical Payment:
No Coverage
1,000
2,000
2,500
5,000
10,000
15,000
20,000
25,000
50,000
100,000
Deductible Information
Motorcycle 1
Motorcycle 2
Motorcycle 3
Motorcycle 4
Comp (Theft)
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
Collision
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
Miscellaneous Information
Current Insurance Company:
Expiration Date:
Current Premium $:
Questions or Comments
to help the Agent:
