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  Gerry Smith Insurance Agency
12280 Nicollet Ave, Suite 104
Burnsville, MN 55337-1999

Ph  (952) 224-7029
Fax (952) 224-0400
gsmith@mnchoiceinsurance.com

 

 
 
Minnesota Motorcycle Insurance Quote Inquiry Form
This inquiry form will allow us to provide you with a motorcycle insurance cost and coverage summary, based on the information that you enter below. 

Note: This is not an application for insurance coverage.  

We recommend that you have a current copy of your insurance policy or declarations page to refer to as you are completing this form. When you have finished entering your information, click the 'Submit' button at the bottom of the page.

PERSONAL  INFORMATION

First Name   MI  
Last Name
Address
City
State
Zip Code

Disclaimer
To provide an accurate quote we will ask you a series of questions, some of which we will confirm through consumer reports which may include credit information. This information will be available to our representatives only. For more information, see our Privacy Statement. Do you want to continue?

I have read the disclaimer and want to continue: Yes No

RIDER INFORMATION

  Rider One Rider Two
First Name
Last Name
Date of Birth
Gender
Male    Female
Male    Female
Marital Status
  
Single  Married 
 
Single  Married 
Bike Organization Member
Relationship to Rider One
Drivers Lic #
State of Lic
Years of Motorcycle Riding Experience

 

DRIVING HISTORY

List all moving violations and claims in the past 5 years

  Incident 1 Incident 2 Incident 3 Incident 4
Rider  One Mo/Yr  Mo/Yr Mo/Yr  Mo/Yr 
Rider Two Mo/Yr  Mo/Yr  Mo/Yr  Mo/Yr 
 

 MOTORCYCLE INFORMATION

  Motorcycle 1 Motorcycle 2
Year
Make
Model
Style
CCs
Altered/Modified
Yes     No
Yes     No
Primary Rider
Vehicle Usage
 

LIABILITY COVERAGES

Personal Liability
Bodily Injury  $                                Property Damage  $
Uninsured/Underinsured Motorist $
Medical Payments $
 

ADDITIONAL COVERAGES

  Motorcycle 1 Motorcycle 2
Comprehensive
Collision
Towing
Yes    No
Yes    No
Optional Equipment (above $2,000)
Value  $
Value  $

 

INSURANCE  INFORMATION

Current Insurance Company
Length of Continuous Insurance
Renewal/Expiration Date

 

CONTACT  INFORMATION

Preferred Method of Contact
 
E-mail
Phone Number
Fax Number
Postal Mailing Address
Questions or Comments
 

Please press the Submit button.
Wait a few moments for an online acknowledgment.

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