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A Service of Simons
Insurance Agency
12743 Bellflower Blvd.
Downey, CA 90242
Toll Free: 888-646-2366
Local Phone: 562-803-3101
Fax: 800-346-2245
satisfaction
On-Line Motorcycle Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
YOUR PERSONAL DATA
Your Name
Street Address
City
State: (Must be California)
Zip Code
E-Mail (REQUIRED)
E-Mail again for accuracy
Phone
Fax (optional)
Marital Status:
Single      Married
Homeowner?
Yes      No
Currently Insured?
(If yes, list carrier, and # of years
continuous. If no, type NONE)
DRIVER INFORMATION #1
Name
Birthdate
Sex
# Years U.S.Auto License
Cycle Safety Course?
# Years U.S.
 Cycle License
Number & Type of Accidents within last 3 years
Number & Type of MINOR violations within last 3 years
Number & Type of MAJOR violations within last 3 years
Daily commute
in ONE WAY miles
Does Driver need an SR22 FILING?
Yes     No
Comments or Remarks?
DRIVER INFORMATION #2 (if none, leave blank)
Name
Birthdate
Sex
# Years U.S.Auto License
Cycle Safety Course?
# Years U.S.
 Cycle License
Number & Type of Accidents within last 3 years
Number & Type of MINOR violations within last 3 years
Number & Type of MAJOR violations within last 3 years
Daily commute in ONE WAY miles
Does Driver need an SR22 FILING?
Yes     No
Comments or Remarks?
VEHICLE #1 INFORMATION
Year of vehicle
Make & Model
Is this a 4 Wheeler?
If Yes, Describe
Annual Mileage
# of CC's
Value of Bike
Special Equipment Value
VEHICLE #1 COVERAGES
Limits of Liability
$15/30 BI / 10 PD
$25/50 BI / 15 PD
$50/100 BI / 50PD
$100/300 BI / 50PD
Comprehensive & Collision
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes      No
Uninsured Motorists Coverage?
YES      NO
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle
Make & Model
Is this a 4 Wheeler?
If Yes, Describe
Annual Mileage
# of CC's
Value of Bike
Special Equipment Value
VEHICLE #2 COVERAGES
Limits of Liability
$15/30 BI / 10 PD
$25/50 BI / 15 PD
$50/100 BI / 50PD
$100/300 BI / 50PD
Comprehensive & Collision
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes      No
Uninsured Motorists Coverage?
YES      NO
Send my quotation via:
E-Mail                  Fax
Regular Mail      Call Me by Phone
Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.
Yes, I Agree. Please Send Me a Motorcycle Quote NOW!
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Simons Insurance Agency
CA License #0772640
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