MOTORCYCLE INSURANCE QUOTE

Fischer, Rounds & Associates, Inc. health insurance agents can assist you with finding the best life insurance policies at the best possible price.

If you would like an agent to contact you directly, simply complete the following information and submit: Location, Name, Phone, Email.

Select location to receive your information: Required

Pierre

Rapid City

Mitchell

Sioux Falls

Watertown

Name Required

Garaging Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Phone Required

Email Address Required

MAILING ADDRESS (IF DIFFERENT FROM ABOVE)

Address 1

Address 2

City

Country

State/Province

Postal Code

DRIVER 1 INFORMATION

First Name

Last Name

Gender

Male

Female

Marital Status

Single

Married

Divorced

Widowed

Separated

Years Licensed

State Licensed

Occupation

Date of Birth

Year cycle license received

DRIVER 2 INFORMATION

First Name

Last Name

Gender

Male

Female

Marital Status

Single

Married

Divorced

Widowed

Separated

Years Licensed

State Licensed

Occupation

Date of Birth

Year cycle license received

VEHICLE 1

Year

Make

Model

VIN Number

Number of Wheels

Engine Size

Modified?

Yes

Owner Usage

Commute

Pleasure

Business

Garaged?

Yes

VEHICLE 2

Year

Make

Model

VIN Number

Number of Wheels

Engine Size

Modified?

Yes

Owner Usage

Commute

Pleasure

Business

Garaged?

Yes

VIOLATION INFORMATION

Last 3 years (minor violations)
Last 5 years (major violations)

DRIVER 1

Minor violations - speeding, turn, stop sign, red light, etc.

Accidents - not at fault

Accidents - at fault

Major violations - drunk driving, reckless, hit and run, etc.

DRIVER 2

Minor violations - speeding, turn, stop sign, red light, etc.

Accidents - not at fault

Accidents - at fault

Major violations - drunk driving, reckless, hit and run, etc.

COVERAGE INFORMATION

BODILY INJURY

Personal Liability

Guest Passenger Liability

Yes

Emergency Roadside Assistance

Yes

Uninsured Motorist

Underinsuranced Motorist

Medical Payment

PROPERTY DAMAGE

Personal Liability

VEHICLE 1

Comprehensive

100

250

500

1,000

1,500

2,000

Collision

100

250

500

1,000

1,500

2,000

VEHICLE 2

Comprehensive

100

250

500

1,000

1,500

2,000

Collision

250

500

1,000

1,500

2,000

MISCELLANEOUS INFORMATION

Current Insurance Company

Expiration Date

Americas/Chicago

Current Premium

Questions or Comments

RELATED DOCUMENTS

Document 1

Document 2

Document 3

If you have a youthful operator with a 3.0 grade point average or better, please indicate name in Comments section.

Please Note: Insurance coverage cannot be bound without a completed application and premium paid.

Additionally, Please Note: Many insurance carriers use information gathered from you and outside sources about your claim, driving and credit history. This information allows insurance companies to determine accurately the proper price to charge. You are entitled to a free copy of the reports by contacting the appropriate consumer reporting agency within the next 60 days.

By filling out this quote you agree to the the above terms.