Motorcycle Insurance



Tuttle & Traina Insurance Agency, Inc.	Surety & Insurance Services Richard C. Traina William B. Tuttle Thomas D. Moylan Raoul Cormier
44 Main Street, Post Office Box 489, Sterling, MA 01564
Phone: (978) 422-7700 Fax: (978) 422-8106

Please completely fill out the form below, submit it to us, and we will contact you with a quote.

Personal Information
Name:
Address Line #1:
Address Line #2:
City:
State/Province:
Country:
Zip/Postal Code:
Day Time Phone Number:
Night Time Phone Number:
Best Time To Call:
E-Mail Address:
Preferred Method Of Contact:
Occupation:
How Long At Present Job:
SS/SIN Number:
We need your SS/SIN number in order to do an SDIP check to properly establish your rates.
Have you had any judgments, liens, or bankruptcies in the last 7 years?
If yes to the above question please explain just below.

Current Insurance Information
Company Name:
Policy Expiration:
Premium Amount:	$ (Optional)
Current Coverage Or Bodily Injury Amount:	$
Continuously Insured For The Last:
Have you ever had insurance cancelled, denied, or non-renewed?
If yes why?

Motorcycle #1 Information
Make:
Model:
Year:
Motorcycle Type:
CC's:
Name Of Title Holder:
Vehicle ID (VIN):
Has This Motorcycle Been Modified?
If Yes To The Above Question, What Is The Value Of Modifications?	$
Is This A Custom Motorcycle?
If Yes To The Above Question, What Is The Appraised Value Of The Motorcycle?	$
This Motorcycle Is Driven To Work/School:	Miles
This Motorcycle Has An Alarm:
This Motorcycle Is Stored In:
If This Motorcycle Is Not Kept At The Above Address, Please Provide The Information Below:
City: State: Zip:
Motorcycle #2 Information
Make:
Model:
Year:
Motorcycle Type:
CC's:
Name Of Title Holder:
Vehicle ID (VIN):
Has This Motorcycle Been Modified?
If Yes To The Above Question, What Is The Value Of Modifications?	$
Is This A Custom Motorcycle?
If Yes To The Above Question, What Is The Appraised Value Of The Motorcycle?	$
This Motorcycle Is Driven To Work/School:	Miles
This Motorcycle Has An Alarm:
This Motorcycle Is Stored In:
If This Motorcycle Is Not Kept At The Above Address, Please Provide The Information Below:
City: State: Zip:
Motorcycle #3 Information
Make:
Model:
Year:
Motorcycle Type:
CC's:
Name Of Title Holder:
Vehicle ID (VIN):
Has This Motorcycle Been Modified?
If Yes To The Above Question, What Is The Value Of Modifications?	$
Is This A Custom Motorcycle?
If Yes To The Above Question, What Is The Appraised Value Of The Motorcycle?	$
This Motorcycle Is Driven To Work/School:	Miles
This Motorcycle Has An Alarm:
This Motorcycle Is Stored In:
If This Motorcycle Is Not Kept At The Above Address, Please Provide The Information Below:
City: State: Zip:
Liability Limits - All Motorcycles Choose EITHER Bodily Injury & Property Damage OR Single Limit
Bodily Injury & Property Damage	Single Limit

Deductibles & Miscellaneous
Car #	Comprehensive Deductible	Collision Deductible	Towing	Loss Of Use
1
2
3

Driver #1 Information
Name	Relation	Date Of Birth	Sex
	Self
Marital Status	Courses Completed In The Last 3 Years

Driver #1 License Information
License Number:		State:	Years Licensed:
Driver #2 Information
Name	Relation	Date Of Birth	Sex

Marital Status	Courses Completed In The Last 3 Years

Driver #2 License Information
License Number:		State:	Years Licensed:
Driver #3 Information
Name	Relation	Date Of Birth	Sex

Marital Status	Courses Completed In The Last 3 Years

Driver #3 License Information
License Number:		State:	Years Licensed:
Driver #4 Information
Name	Relation	Date Of Birth	Sex

Marital Status	Courses Completed In The Last 3 Years

Driver #4 License Information
License Number:		State:	Years Licensed:

Driver History
Please list ANY convictions for ANY driver convicted of moving traffic violation in the past 3 years.
Driver #	Date Of Incident	Type Of Conviction		Speed Over The Limit
				mph
				mph
				mph
				mph
Please list ANY driver who has had license suspensions, revocations, or driving under the influence convictions.
Driver #	License Suspended Or Revoked?		D.U.I. Conviction For?




Please list ANY driver involved in accidents, regardless of fault, in the past 5 years.
Driver #	Date	Description	Cost	Injuries / At Fault
			$
			$
			$
			$

Additional Comments
Please leave any comments or additional information here.

By clicking the button below I understand this is for quotation purposes only and is in no way intended to act as a formal application or an insurance binder.