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Ricketson Insurance

and Realty, Inc.

      

Motorcycle Quote

Name
Street Address
Address
City
State Zip
County
Date of Birth
Are you married or single?
How many drivers are there?
Have you had any accidents or violations in the last 3 years?

If so when?

Date Type of accident or violation Was there an at fault accident?

Motorcycle Information

Year Make
Model
CC's
Is the bike from a factory? 
Years of motorcycle experience. (On road experience ONLY) 
Do you have prior insurance? 
Is it expired or currently in force?
If it is current what is the expiration date of the current policy? 
Are you a homeowner?
Have you had a riders training course in the last 3 years?

Coverages

Liability / Uninsured Motorists / Medical Payments

Liability Limit - Bodily Injury
Liability Limit - Property Damage

Uninsured/Underinsured Motorists Limit
Uninsured/Underinsured Motorists Property Damage

Medical Payments - Per Person Limit


Physical Damage Coverage & Deductibles

Vehicle

Comprehensive Deductible

Collision Deductible

Towing

Rental

1.

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Ricketson Insurance & Realty Inc.
P.O. Box 921 - 955 Augusta Rd.
Thomson, GA 30824
Phone: (706) 595-4354
Toll Free: (800) 613-5874
Fax: (706) 595-9225

September 21, 2005

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