Name:_______________________________ Date:_______

Address:_____________________________

City/State/Zip:________________________

List All operators of the Motorcycle/s:

Name:___________________Date of Birth:________Yrs.Experience:____Accidents or Violations__yes__no

Name:___________________Date of Birth:________Yrs.Experience:____Accidents or Violations:__yes__no

Name:___________________Date of Birth:________Yrs.Experience:____Accidents or Violations:__yes__no

List All Motorcycles to be quoted:

Year:____Make:________Mdl:_______engine size:______Modified:__yes__no---Garaged__yes__no

Year:____Make:________Mdl:_______engine size:______Modified:__yes__no---Garaged__yes__no

Year:____Make:________Mdl._______engine size:______Modified:__yes__no---Garaged__yes__no

Select Coverages you would like quoted:

__15,000/30,000.Bodily Injury Liability with 10,000.Property Damage Liability (PA State Min.)

__25,000/50,000.Bodily Injury Liability with 10,000.Property Damage Liability

__50,000/100,000.Bodily Injury Liability with 25,000.Property Damage Liability

__100,000./300,000.Bodily Injury Liability with 50,000.Property Damage Liability

Do you wish Uninsured and Underinsured Motorist coverages quoted __yes __no

Physical Damage Coverage Deductibles (coverage on the bike itself) "optional coverage"

Comprehensive: ___$100. ___$250. ___$500.

Collision: ___$250. ___$500. ___$1,000.

If you indicated any accidents or violations, please give details here (dates & description):

past 3 years only:______________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

If you indicated any modifications for any of the motorcycles, please describe here:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Credits available:

Have all operators completed a motorcycle safety riders course __yes __no

Do you presently have all motorcycles insured __yes __no

Do you own your home __yes __no

Are all operators members of AMA (American Motorcycle Assoc.) __yes __no

Thank you for your time. Please return this to us at the address below or fax it to us at the fax

number shown below. Also be sure and indicate how you would like us to forward your quote

to you.

Thanks again!!

The Rhode Agency Inc.

Main & Noble Sts.

P.O. Box 246

Kutztown, PA 19530

Phone #: 610-683-3565

Fax #: 610-683-9465

e-mail: info@rhodeagency.com

Call me with my quote:____

Mail my quote to me:____

e-mail my quote to me at:___________________________