Mark W Insurance and Insurance Countrywide; servicing Georgia customers for over 20 years!
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Mark W Insurance Agency
4336 Covington Hwy #106
Decatur, GA 30035
(404)288-2837
Insurance Countrywide
2171 Old Concord Rd. Suite #100
Smyrna, GA 30080
(770) 432-0709
Motorcycle Quote:
Named Insured:
First Name
*
Last Name
*
Date of Birth
*
Street Address:
City:
State:
ZIP:
Daytime Phone
*
(or phone number that is best to reach you)
Night Time Phone
What is your e-mail address?
How did you hear about us?
From a Progressive/Drive Insurance Featured Ad
From a non-Progressive/Drive Insurance Ad
From a friend or other word of mouth
Other
If Other, please tell us where you heard about us:
Is the Named Insured currently married?
No
Yes
Has the Named Insured been insured within the last 30 days for atleast six months, continuously?
No
Yes
If Yes to above, please indicate if available:
Prior Company
Policy number
Expiration date
Drivers
How many drivers would you like to be listed on your policy?
1
2
3
4
5+
Driver 1 (Must be Named Insured!)
First Name
Last Name
Date of Birth
Married?
No
List all tickets and accidents in the last 3 years
About how many years of motorcycle riding experience does this driver have?
Has this driver completed a motorcycle safety course?
(Must provide certificate or proof of completion!)
No
Yes
Driver 2 (Spouse, if applicable)
First Name
Last Name
Date of Birth
Married?
No
Yes
List all tickets and accidents in the last 3 years
About how many years of motorcycle riding experience does this driver have?
Has this driver completed a motorcycle safety course?
(Must provide certificate or proof of completion!)
No
Yes
Driver 3
First Name
Last Name
Date of Birth
Married?
No
Yes
List all tickets and accidents in the last 3 years
About how many years of motorcycle riding experience does this driver have?
Has this driver completed a motorcycle safety course?
(Must provide certificate or proof of completion!)
No
Yes
Driver 4
First Name
Last Name
Date of Birth
Married?
No
Yes
List all tickets and accidents in the last 3 years
About how many years of motorcycle riding experience does this driver have?
Has this driver completed a motorcycle safety course?
(Must provide certificate or proof of completion!)
No
Yes
5 or More Drivers (May require special handling)
List all additional drivers, including:
First and Last Name
Date of Birth
Marital Status
All tickets and accidents for the last three years
Number of years of motorcycle riding experience
Which, if any, drivers have completed a motorcycle safety course
Vehicles
How many vehicles would you like to be listed on your policy?
1
2
3
4
5+
Vehicle 1
Year
Make
Model
Engine Size (cc)
Enter the vehicle I.D. Number (VIN)
(If available)
Please indicate any special customizations
(Modified frame, trike conversion etc)
Full Coverage (Comprehensive/Collision)
Rental/Roadside Assist requires Comprehensive/Collision!
Rental and Towing/Roadside Assist
No
Yes
Comprehensive/Collision Deductibles
No Full Coverage
$100/$100
$250/$250
$500/$500
$1000/$1000
$100/$250
$100/$500
$100/$1000
Please enter the dollar amount in custom equipment on this bike
(Most companies provide some custom equipment coverage free of charge; please ask the agent how much your quoted company provides)
Vehicle 2
Year
Make
Model
Engine Size (cc)
Enter the vehicle I.D. Number (VIN)
Please indicate any special customizations
(Modified frame, trike conversion etc)
Full Coverage (Comprehensive/Collision)
Rental/Roadside Assist requires Comprehensive/Collision!
Rental and Towing/Roadside Assist
No
Yes
Comprehensive/Collision Deductibles
No Full Coverage
$100/$100
$250/$250
$500/$500
$1000/$1000
$100/$250
$100/$500
$100/$1000
Please enter the dollar amount in custom equipment on this bike
(Most companies provide some custom equipment coverage free of charge; please ask the agent how much your quoted company provides)
Vehicle 3
Year
Make
Model
Engine Size (cc)
Enter the vehicle I.D. Number (VIN)
Please indicate any special customizations
(Modified frame, trike conversion etc)
Full Coverage (Comprehensive/Collision)
Rental/Roadside Assist requires Comprehensive/Collision!
Rental and Towing/Roadside Assist
No
Yes
Comprehensive/Collision Deductibles
No Full Coverage
$100/$100
$250/$250
$500/$500
$1000/$1000
$100/$250
$100/$500
$100/$1000
Please enter the dollar amount in custom equipment on this bike
(Most companies provide some custom equipment coverage free of charge; please ask the agent how much your quoted company provides)
Vehicle 4
Year
Make
Model
Engine Size (cc)
Enter the vehicle I.D. Number (VIN)
Please indicate any special customizations
(Modified frame, trike conversion etc)
Full Coverage (Comprehensive/Collision)
Rental/Roadside Assist requires Comprehensive/Collision!
Rental and Towing/Roadside Assist
No
Yes
Comprehensive/Collision Deductibles
No Full Coverage
$100/$100
$250/$250
$500/$500
$1000/$1000
$100/$250
$100/$500
$100/$1000
Please enter the dollar amount in custom equipment on this bike
(Most companies provide some custom equipment coverage free of charge; please ask the agent how much your quoted company provides)
5 or More Vehicles (May require special handling)
List all additional vehicles, including:
Year
Make
Model
Engine size (cc)
Vehicle I.D. Number (VIN)
Indicate any customizations (trike conversion, modified frame etc.)
Indicate which vehicles need Full Coverage (Comprehensive and Collision), what deductible you'd like and if you'd like Rental/Towing Coverage
Indicate amount of custom equipment coverage needed
Liability Coverages
If you are transferring from another company, please select coverages identical to those listed on your prior/existing policy.
Bodily Injury / Property Damage Liability
(Includes Guest Passenger Liability)
$25,000/$50,000/$25,000
$50,000/$100,000/$25,000
$50,000/$100,000/$50,000
$100,000/$300,000/$50,000
$100,000/$300,000/$100,000
$250,000/$500,000/$100,000
$300,000 Single-Limit
$500,000 Single-Limit
Uninsured Motorists Coverage Limits
Note: You may only select Uninsured Motorists Limits as high as your Bodily Injury/Property Damage Limits!
$25,000/$50,000/$25,000
$50,000/$100,000/$25,000
$50,000/$100,000/$50,000
$100,000/$300,000/$50,000
$100,000/$300,000/$100,000
$250,000/$500,000/$100,000
$300,000 Single-Limit
$500,000 Single-Limit
When finished, please hit the 'SUBMIT' button below
[ Office hours are Monday-Friday 9AM-6PM; Insurance Countrywide is open on Saturday from 10AM-4PM ]
Decatur
Smyrna
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