Motorcycle and ATV Insurance Quote Request 2016-12-13T12:10:34+00:00

MOTORCYCLE AND ATV INSURANCE
QUOTE REQUEST

We at Hudson & Muma believe that it is important to offer our customers the most up-to-date technology available which will enhance the service they receive. It is because of this commitment that we are offering this form to aid in generating accurate applications and forms quickly and efficiently!

Remember, without complete information, we may be delayed in producing your quote, so please complete ALL applicable fields.

SUBMITTING THIS FORM YOU ARE AGREEING TO THE CONDITION THAT NO MATERIAL CHANGE WILL BE MADE TO YOUR POLICY UNLESS AND UNTIL YOU RECEIVE CONFIRMATION OF THAT CHANGE FROM A HUDSON & MUMA ASSOCIATE OR AN ASSOCIATE THAT THE INSURANCE COMPANY WRITING THE COVERAGE.
* Indicates required fields


Quote Effective Date:

Insured Information

Type of Customer*:
Personal CustomerCommercial Customer








Preferred Method of Contact:

Previous Address (if moved within the last 2 years or if home is a new purchase):

 


 

Insured Birth Date:

Occupation*:

Insured's Education:

Spouse:

Spouse Birth Date:

Spouse Occupation:

Spouse's Education:

Member of any Associations or Clubs (possible discount)(e.g. Alumni, Chamber of Commerce, Trade Assoc.):

Current Insurance:

Current Insurance Company:

If NONE, is this:

Prior Policy Number:

Prior Policy Expiration Date:

Has Your Insurance Ever Been Cancelled or Non-Renewed?*:YesNo

If Yes, Why?

 


 

Driver Information:

Driver 1:







Driver 2:







Driver 3:






 


 

Vehicle Information:

Vehicle 1:







LoJack® Device installed on this vehicle?: YesNo

Vehicle 2:







LoJack® Device installed on this vehicle?: YesNo

Vehicle 3:







LoJack® Device installed on this vehicle?: YesNo

 


 

Physical Damage Coverage Information:

Vehicle 1:
Collision Deductible: Comprehensive Deductible:Collision Type:Alarm Type:

Vehicle 2:
Collision Deductible: Comprehensive Deductible:Collision Type:Alarm Type:

Vehicle 3:
Collision Deductible: Comprehensive Deductible:Collision Type:Alarm Type:

 


 

OTHER OPTIONS:

 

Vehicle 1

Rental/Loss of Use

Towing/Road Service

Accessory Coverage, put in an amount in Thousands between $1,000 - $30,000

 

Vehicle 2

Rental/Loss of Use

Towing/Road Service

Accessory Coverage, put in an amount in Thousands between $1,000 - $30,000

 

Vehicle 3

Rental/Loss of Use

Towing/Road Service

Accessory Coverage, put in an amount in Thousands between $1,000 - $30,000

 


 

Do you have a transportation trailer? If so, please enter, year, make, model, Vin number and Value:

 


 

TICKETS/ACCIDENTS

Driver 1:

Describe, including Dates and any claim amounts:

Driver2:

Describe, including Dates and any claim amounts:

Driver3:

Describe, including Dates and any claim amounts:

 


 

LIABILITY COVERAGE

The state-required minimum in Michigan is liability insurance with at least the following amounts:

$20,000 bodily injury per person
$40,000 bodily injury per incident
$10,000 property damage pre incident
If you ever cause an accident on your bike, liability kicks in to give others' the help they need with damages, protecting your hard-earned savings in the process.

Keep in mind you'll be able to select higher liability limits, as well as a bevy of optional coverages, for your policy when you get your quote.

Bodily Injury Accident/Occurrence Split Limits:

Property Damage:

Combined Single Limit BI/PD:

Uninsured/Underinsured Motorist Split Limits:

Uninsured/Underinsured Motorist Combined Single Limit:

 


 

Michigan motorcycle Helmet law:

1. A motorcycle OPERATOR can ride without a helmet when all of the following conditions have been satisfied:
(a) The operator is 21 years or older;
(b) The operator has had a motorcycle endorsement on his or her driving license for not less than
two years, or the operator has passed a motorcycle course under § 811 of the Michigan Motor
Vehicle Code; and
(c) The operator has purchased “first-party medical benefits” under § 3103 of the Michigan No-Fault
Act in amounts not less than $20,000 per person and $20,000 per occurrence, unless the
operator’s passenger purchased at least $20,000 of this coverage, in which case, the operator
only needs to purchase this coverage in the amount of $20,000 per person.

2. Motorcycle passengers can ride without a helmet when all of the following conditions have
been satisfied:
(a) The passenger is 21 years or older; and
(b) The motorcycle operator has purchased “first party medical benefits” under § 3103 of the
Michigan No-Fault Act in amounts not less than $20,000 per person and $20,000 per occurrence,
or in lieu thereof, the passenger purchased this coverage in an amount not less than $20,000 per
person.

 


 

Vehicle 1, First Party Medical benefits*:

 

Vehicle 2, First Party Medical benefits*:

 

Vehicle 3, First Party Medical benefits*:

 


 

ADDITIONAL INTEREST(S)

Vehicle 1:

Interest Type:

Address:

Vehicle 2:

Interest Type:

Address:

Vehicle 3:

Interest Type:

Address:

 


 

NOTES:

Referred By:

Who Writes Your Life Insurance:

 


 

Attachments:

If you have a sample from the Certificate Holder or certain portions of a contract that specify what is needed, please attach here.


Name of person completing form:*

Confirmation Email Address:*
(We need this to send you a confirmation receipt for this form.)