Motorcycle Rate Estimate Request

Please complete the following information as accurately as possible. Quoted rates will be based on the accuracy and completeness of the information provided. All Rates are subject to change. 

All Information provided is for the exclusive use of  CHEAP Insurance Agency / Bucheli Insurance Agency, Inc.

California License 0F27296

Skip any fields that do not apply.

Your Name  

Address       

City                  State     CA ONLY!!!

Zip Code (Required)   

Telephone  (With Area Code)        

Fax            (With Area Code)    

Email Address - Required!    

Do you have a valid Motorcycle Operator License?  Yes No

If Yes, how many years have you been Licensed?

Do you belong to any Motorcycle Associations? If so please list:

Vehicle Information

                Year           Make                       Model          Annual Miles

Vehicle 1           

Vehicle 2           

Vehicle Use

Vehicle 1                                 Vehicle 2

Pleasure Commute - Work / School Business Delivery   N\A Pleasure Commute - Work / School Business Delivery

Driver Information

  Driver 1 Name                      Years Licensed        Date of Birth

Primary Driver of             Sex                       Marital Status?

Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4                 Male Female                Single Married

Please List Any Accidents or Violations (in the last 3 years) 

 Driver 2 Name                     Years Licensed        Date of Birth

Primary Driver of              Sex                        Marital Status?

N\A Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4                 N\A Male Female                  N\A Single Married

Please List Any Accidents or Violations (in the last 3 years) 

 Coverage Limits

Uninsured  / Underinsured Motorist 

None $15,000 person, $30,000 per accident $25,000 per person, $50,000 per accident $50,000 per person, $100,000 per accident $100,000 per person, $300,000 per accident $250,000 per person, $500,000 per accident   

Medical Payments    $1,000 $5,000 $10,000     

Liability Limits

Bodily Injury    $15,000 per person, $30,000 each accident $25,000 per person, $50,000 each accident $50,000 per person, $100,000 each accident $100,000 per person, $300,000 each accident $250,000 per person, $500,000 each accident    

Property Damage $5,000 each accident $10,000 each accident $25,000 each accident $50,000 each accident $100,000 each accident  

Deductibles

                    Comprehensive Coverage            Collision Coverage

Vehicle #1       No Coverage $100 deductible $200 deductible $250 deductible $500 deductible $1,000 deductible               No Coverage $250 deductible $500 deductible $1,000 deductible

Vehicle #2       No Coverage $100 deductible $200 deductible $250 deductible $500 deductible $1,000 deductible               No Coverage $250 deductible $500 deductible $1,000 deductible

Do you currently have insurance?                         Yes No

How long have you had uninterrupted Insurance Coverage?

No coverage 3 months 6 months 1 year 2 years 3 years or more

What is the expiration date of your current policy?  

When would you like to have this policy start?