Mayo Associates, Northfield, Vermont

VERMONT Motorcycle Insurance Quote Form:

Please Note: WE CAN NOT QUOTE ON OUT OF STATE INSURANCE.

Name:
Address:
City, State, Zip:
Phone Number:
E-Mail:

Cycle Information

#	Year	Cycle Description	Comprehensive Deductible	Collision Deductible
1			$50 $100 $250 No Comp.	No Coll. $150 $250
2			$50 $100 $250 No Comp.	No Coll. $150 $250
3			$50 $100 $250 No Comp.	No Coll. $150 $250
4			$50 $100 $250 No Comp.	No Coll. $150 $250

Was any equipment or accessory added to the vehicle other than those supplied by the manufacturer?
Yes No; What is the added value? $

Driver Information

#	Driver Name	Birth Date	Sex	Marital Status	Years Licensed
1			Male Female	Single Married
2			Male Female	Single Married
3			Male Female	Single Married
4			Male Female	Single Married

Liability & Other Coverages

Body Injury Liability:	$50,000/$100,000 $100,000/$300,000 $250,000/$500,000 Per Person/Accident
Property Damage Liability:	$25,000 $50,000 $100,000

Accidents and Violations
Have you had any accidents or violations in the past 3 years?
Yes No
If Yes, Please list...

#	Date	Type of Occurrence	Driver's Name
1		None Speeding < 15 MPH Speeding > 15 MPH DWI Other minor violation Other major violation Not-at-fault accident At-fault accident Other
2		None Speeding < 15 MPH Speeding > 15 MPH DWI Other minor violation Other major violation Not-at-fault accident At-fault accident Other
3		None Speeding < 15 MPH Speeding > 15 MPH DWI Other minor violation Other major violation Not-at-fault accident At-fault accident Other
4		None Speeding < 15 MPH Speeding > 15 MPH DWI Other minor violation Other major violation Not-at-fault accident At-fault accident Other

For additional information, please e-mail us at:

MAYO@mayo-insurance.com

Call at 1-802-485-6061 or

1-800-982-5849

or fax us at 1-802-485-6065.

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© 1996 Mayo Associates, Inc.
49 Wall Street
Northfield, Vermont 05663
MAYO@mayo-insurance.com