Bimota, BMW, Buell, Caviga, Ducati, Gilera, Harley Davidson, Honda, Indian, Kawasaki, Suzuki, Triumph and Yamaha

From the venerible Hog to the Honda Hurricane, we insure them all. Since 1988, when it comes to motorcycles and insurance, we'll ride you through to better rates, better coverage and better service.

   

DIAL TOLL FREE
1-877-901-5544
(309) area code dial 673-5544
ILLINOIS RESIDENTS ONLY

  
GENERAL INFORMATION
  
To assure the security and confidentiality of your personal information this document is being viewed and submitted through Ledbetter Insurance's SSL/secured channels.
Your Name:

Mailing Address:

City:

State:  Illinois
Zip/Postal:

Social Security #:

Drivers License #:

E-Mail 

Phone:

Fax 

 

Marital Status:

Single Married

Homeowner?

Yes No

Is Bike Kept in a Locked Structure?

Yes No

Do You Have a Motorcycle License?

Yes No

FIRST DRIVER INFORMATION
Name: Birth date:
Sex (M/F): # Years Experience:

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 of Accidents: Number of violations:

Does Driver need an SR22 FILING?

 Yes No

If YES to SR filing, why needed?
(List accident/cite below in Additional Information)

SECOND DRIVER INFORMATION 
Name: Birth date:
Sex (M/F): # Years Experience:

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 of Accidents: Number of violations:

Does Driver need an SR22 FILING?

 Yes No

If YES to SR filing, why needed?
(List accident/cite below in Additional Information)

FIRST VEHICLE INFORMATION
Year: Model Number:  
Make: VIN:  

FIRST VEHICLE COVERAGE

  
Limits of Liability: $20/40 BI / 15 PD  $25/50 BI / 25 PD
$50/100 BI / 25 PD $100/300 BI / 50 PD		  
 
Comprehensive: NO Coverage   $250 Deductible
$500 Deductible $1000 Deductible		  
 
Collision: NO Coverage   $250 Deductible
$500 Deductible $1000 Deductible		  
 

Medical Coverage

 NO Coverage $500 $1000 $5000
 

Uninsured Motorist Property Damage:

 Yes No
 

Special Equipment Coverage Amount:

 $  
 

Towing

 Yes No
 

Are You the Registered Owner?

 Yes No

SECOND VEHICLE INFORMATION

Year: Model Number:
Make: VIN:

SECOND VEHICLE COVERAGE
Limits of Liability: $20/40 BI / 15 PD  $25/50 BI / 25 PD
$50/100 BI / 25 PD $100/300 BI / 50 PD
 
Guest Passenger Liability: Yes No
 
Comprehensive: NO Coverage   $250 Deductible
$500 Deductible $1000 Deductible
 
Collision: NO Coverage   $250 Deductible
$500 Deductible $1000 Deductible
 

Medical Coverage

 NO Coverage $500 $1000 $5000
 

Uninsured Motorist Property Damage:

 Yes No
 

Special Equipment Coverage Amount:

 $    
 

Towing

 Yes No
 

Are You the Registered Owner?

 Yes No
DISCOUNTS
Prior insurance last twelve months? Yes No
Have taken the safety rider course? Yes No
Have you owned the same bike for 12 months? 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
If you have any tickets, accidents or need SR22 Filing please explain here.
Also provide information about additional drivers and/or vehicle here.