ATV, Golf Cart, Dune Buggy and Scooter Quote Form


GENERAL INFORMATION
Named Insured:
Mailing Address:
City:
State:	Illinois
Zip/Postal:
Social Security #:
Drivers License #:
E-Mail
Date of Birth:
Phone:
Fax

UNIT INFORMATION
Years of ATV Driving Exp:
Years of Dune Buggy Driving Exp:
Years of Golf Cart Driving Exp:
Years of Scooter Driving Exp:
Have you taken the safety rider course?:	Yes No
Any Accidents Last 36 Months? (Please list all accidents in box below)	Yes No
Have your had this type of vehicle the last six months?	Yes No

State:
County:

UNIT INFORMATION
Is unit kept in a fully enclosed, locked structure?:	Yes No
Model Year:
Make:		Model:
Units Engine Size/CC's:		Current Value of Unit:

COVERAGES
Bodily Injury/Property Damage:	$20/40 BI / 15 PD $25/50 BI / 25 PD $50/100 BI / 25 PD $100/300 BI / 50 PD $100/300 BI / 100 PD $250/500 BI / 100 PD
Passenger Liability:	Yes No
Medical:	$500 $1000 $2000 $5000
Uninsured Motorists Coverage:	Yes No
Deductible on Unit:	$100 $250 $500 $1000
Coverage for Transport Trailer Unit:	Yes No $

NOTICE: Some companies use an insurance score. This can often improve your rate. If you would like us to use this underwriting tool please provide us your social security number above in the dedicated box or in the remarks box below.

(Rules of the Fair Reporting Credit Act and Federal Consumer Credit Protection Law, will apply)

ADDITIONAL INFORMATION
Please use this section to explain any violations, accidents or claims/losses.