Your Name:                      Street Address:         

       City:                                  State:                                  KENTUCKY             

       Email:                            Phone:                         

      Marital Status:           Single Married                           Homeowner:              No YES

      Current Insurance Carrier:    Renewal Date:         

--------------------------------------------------------------------------------------------------------

                                                 Driver 1 Information                      

                            Your Name:        Date of Birth:

                                                   Sex:   Male Female                                     Cycle Safety Course: No YES

                                                   # of Accidents in last 3 years:       # of Tickets in last 3 years:

                                                   Years of motorcycle driving experience:

                                     -----------------------------------------------------------------------------------------

                                Driver 2 Information

                            Your Name:        Date of Birth:

                                                   Sex:   Male Female                                     Cycle Safety Course: No YES

                                                   # of Accidents in last 3 years:       # of Tickets in last 3 years:

                                                   Years of motorcycle driving experience:

                                         -------------------------------------------------------------------------------------------------------

                                   Vehicle #1

                                                   Year of Vehicle:              Make :    

                                                    Model:   Vin#       # of CC's:

                                             Vehicle #1 Coverage

              Limits of Liability: 25/50/10        25/50/25          50/100/25      100/300/50                                         

              Comprehensive:        No Coverage $250          $500              $1000                                                

              Collision:                   No Coverage $250     $500       $1000

                          Do you want uninsured motorist cov.? NO YES   Do you want medical cov.? No YES                                                                                                                                                                                                                                  

                                                 -------------------------------------------------------------------------------------------------------------                                            

                                     Vehicle #2

                                                   Year of Vehicle:              Make :    

                                                    Model:   Vin#       # of CC's:

                                                     Vehicle #2 Coverages

             Limits of Liability: 25/50/10        25/50/25          50/100/25      100/300/50                                         

              Comprehensive:        No Coverage $250          $500          $1000                                                

              Collision:                        No Coverage $250     $500       $1000

                      Do you want uninsured motorist cov.? No YES      Do you want medical cov.? No YES

                                 ----------------------------------------------------------------------------------------------------------------------------

                                                  Send my Quote by:   E-Mail      Fax

                                                                                                      Phone       Regular Mail

Please enter your preferred contact information

                                ------------------------------------------------------------------------------------------------------------------------------