Applicant Information

Name of Insured (as it should appear on policy):

D.B.A. Name:

Primary Contact (full name):

Email Address:

Contact is: Owner Site Administrator Rider Coach Other (describe in notes)

Physical Address:

Mailing address (if applicable) :

City, State, ZIP :

Phone number : Fax number:

Nature of Business: Motorcycle Rider Education ATV Rider Education Dirt Bike Rider Education Driver Education Other (describe in notes) Business is: Corporation Partnership Joint Venture Sole Proprietorship State School Other (describe in notes)

In what state is the organization Headquartered/chartered?

When do you need the coverage to begin?

How did you hear about us?

Coverage Information

Type of coverage and limits desired:

General Liability
    Primary $1,000,000 Each Occurrence/$2,000,000 aggregate
    Excess Medical Payments - $10,000 each student

Inland Marine
    Unit Physical Damage - $250 Deductible.    Number of Units:
    Miscellaneous Equipment
    Domino Coverage
    Third Party Testing
    Physical Damage for Instructor's bikes
        ($500 deductible, $50 per bike premium)

Underwriting Information

How many losses in the last 3 years?

Are all applicants required to sign a waiver? Yes No

If a participant is a minor, are the parents or legal guardian required to sign a waiver?
Yes No

Estimate the number of students for the coming year:

Are there formal medical procedures for injured students? Yes No

Are written reports required for all accidents? Yes No

Do you have motorcycles on the loan program? Yes No

Where are your bikes stored?

Please describe your security precautions:

Additional Information

Please include any additional information that may help us process your request.