R.R.I.S. Motorcycle Questionnaire                 

Please provide the following information:    

(The Referral Agent is the name of your Insurance Agent in our office or how you became aware of our website)

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State
Zip/Postal Code
Social Security #
Work Phone
Home Phone
FAX
E-mail
URL

Gender Choose One male female Age Marital Status   Choose One married unmarried divorced Occupation   Driving record for the past 3 years Minor Moving Violations: Choose One 1 2 3 4 5 6 7 8 9 At Fault Accidents: Choose One 1 2 3 4 5 6 7 8 9 Was anyone injured in any accident listed above: Choose One Yes No         Driving record for the past 7 years Number of Major Violations Choose One 1 2 3 4 5 6 7 8 9 License suspended/ revoked Choose One Yes No   If yes, provide details and give the date your license was reinstated:   Additional Driver 1 First Name   Last Name   Gender Choose One male female Age Marital Status   Choose One married unmarried divorced Occupation                 Driving record for the past 3 years Minor Moving Violations: Choose One 1 2 3 4 5 6 7 8 9 At Fault Accidents: Choose One 1 2 3 4 5 6 7 8 9 Was anyone injured in any accident listed above: Choose One Yes No                 Driving record for the past 7 years Number of Major Violations Choose One 1 2 3 4 5 6 7 8 9 License suspended/ revoked Choose One Yes No   If yes, provide details and give the date your license was reinstated:   Additional Driver 2 First Name   Last Name   Gender Choose One male female Age Marital Status   Choose One married unmarried divorced Occupation                 Driving record for the past 3 years Minor Moving Violations: Choose One 1 2 3 4 5 6 7 8 9 At Fault Accidents: Choose One 1 2 3 4 5 6 7 8 9 Was anyone injured in any accident listed above: Choose One Yes No                 Driving record for the past 7 years Number of Major Violations Choose One 1 2 3 4 5 6 7 8 9 License suspended/ revoked Choose One Yes No   If yes, provide details and give the date your license was reinstated:   Motorcycle 1 Year Engine Size Make Model: Use Choose One Pleasure Only To/From Work To School Business Sales Calls Artisan Delivery Farm or Ranch Annual Mileage Choose One 0-7500 7501-15K 15K-22K 22k +         Coverage Liability Limit Choose One 15/30/10 25/50/25 30/60/25 50/100/50 100/300/50 250/500/100 500/500/100 Uninsured Motorist Choose One 15/30 25/50 30/60 50/100 100/300 250/500 500/500 None Medical Payments Choose One 2,000 5,000 10,000 100,000 Comprehensive Choose One None ACV 50 100 120 150 200 240 500 1000 Collision Choose One None ACV 50 100 120 150 200 240 500 1000 Main Driver Motorcycle 2 Year Engine Size Make Model: Use Choose One Pleasure Only To/From Work To School Business Sales Calls Artisan Delivery Farm or Ranch Annual Mileage Choose One 0-7500 7501-15K 15K-22K 22k +         Coverage Liability Limit Choose One 15/30/10 25/50/25 30/60/25 50/100/50 100/300/50 250/500/100 500/500/100 Uninsured Motorist Choose One 15/30 25/50 30/60 50/100 100/300 250/500 500/500 None Medical Payments Choose One 2,000 5,000 10,000 100,000 Comprehensive Choose One None ACV 50 100 120 150 200 240 500 1000 Collision Choose One None ACV 50 100 120 150 200 240 500 1000 Main Driver Motorcycle 3 Year Engine Size Make Model: Use Choose One Pleasure Only To/From Work To School Business Sales Calls Artisan Delivery Farm or Ranch Annual Mileage Choose One 0-7500 7501-15K 15K-22K 22k +         Coverage Liability Limit Choose One 15/30/10 25/50/25 30/60/25 50/100/50 100/300/50 250/500/100 500/500/100 Uninsured Motorist Choose One 15/30 25/50 30/60 50/100 100/300 250/500 500/500 None Medical Payments Choose One 2,000 5,000 10,000 100,000 Comprehensive Choose One None ACV 50 100 120 150 200 240 500 1000 Collision Choose One None ACV 50 100 120 150 200 240 500 1000 Main Driver   Comments and enter additional motorcycles here: Sheri Ritchie / Ritchie & Rose Insurance Services, Inc. Bus  (530) 365-4705   Fax (866) 885-1428   DOI License No.  0F44143 sheriritchie@gmail.com Copyright © 2007 Ritchie & Rose Insurance Services, Inc. All rights reserved. Revised: 06/08/2013 04:16 PM