OREGON MOTORCYCLE INSURANCE

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CONTACT INFORMATION
First Name
Last Name
Address
City
State
Zip
Home Phone
Work Phone
Email
Years at Residence
Insurance Status
Insurance Provider
Date Insurance Expires
Monthly Premium
RIDER INFORMATION
R I D E R 1	First Name
	Last name
	Sex	Male Female
	DOB
	Marital Status
	Education
	Occupation
	Automobile License Status
	Motorcycle Endorsement on Driver's License	Yes No
	In the last 5 yrs has the rider owned or been insured on a motorcycle/ATV?	Yes No
	If YES, total number of calendar years insure
R I D E R 2	First Name
	Last Name
	Sex	Male Female
	DOB
	Marital Status
	Education
	Occupation
	Automobile License Status
	Motorcycle Endorsement on Driver's License	Yes No
	In the last 5 yrs has the rider owned or been insured on a motorcycle/ATV?	Yes No
	If YES, total number of calendar years insure
R I D E R 3	First Name
	Last Name
	Sex	Male Female
	DOB
	Marital Status
	Education
	Occupation
	Automobile License Status
	Motorcycle Endorsement on Driver's License	Yes No
	In the last 5 yrs has the rider owned or been insured on a motorcycle/ATV?	Yes No
	If YES, total number of calendar years insured
MOTORCYCLE INFORMATION
B I K E 1	Year
	Make
	Model
	Engine Size
	VIN
B I K E 2	Year
	Make
	Model
	Engine Size
	VIN
B I K E 3	Year
	Make
	Model
	Engine Size
	VIN
RIDER DISCOUNT
	Association Discount
BODILY INJURY AND PROPERTY LIABILITY
Bodily Injury
Property Damage
Guest Passenger
Uninsured/Underinsured Motorist
PHYSICAL DAMAGE AND TOWING
Comprehensive
Collision
Towing & Labor
ADDITIONAL COMMENTS
	Please Elaborate on any Insurance Claims or Violations within the last 3 years (if any)

INFORMATION DISCLOSURE To offer you a quote from the companies I represent information is collected from consumer reporting agencies. This would include your driving record, claims history with other insurers, and credit report information. When you click on submit you understand this provision. PRIVACY The information that is obtained will be kept confidential, secure and will not be sold or redistributed. We don't sell our customer lists or share your information with other companies to offer their products to you.

Mark Strauss

Insurance Advisor

Office Hours:

8:30 a.m. - 5:15 p.m.

Monday to Friday

Call for a Quote:

503-296-0077

Below are a few of the reputable insurance carriers I represent: