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INSURANCE QUOTE FORM
We appreciate the opportunity to review your insurance needs. Privacy is your right and our concern. All information you provide us will be use by us and the insurance companies we represent for rating purposes only and will not be shared with any one else. We offer three ways to get an insurance quote: Use this web based insurance quote form, use our fax based insurance quote form or call us at 631-476-0722 and get a quote over the phone.

 

Getting An Insurance Quote is Easy!


Web Quote Form: For an accurate quote, please fill in all fields.

Insured's Information

            

Last Name 

 

First Name  

 

Middle Initial  

 

Street Address 

  

City or Town  

 

State  

 
Zip Code    
Date of Birth       
Occupation    

Social Security#  

  
Driver License #      
Contact Phone     
Fax     
E-mail     
 
 
 
 

Motorcycle Information

 

Unit 1

Unit 2 (optional)

Year   Year  
Make   Make  
Model   Model  
CC'S   CC'S  
Vin #    Vin #  

 

 
 
 
 

 

Type of Coverage Desired

 

      What Type of Policy are you looking for?  

Pick Limits of Liability and Physical Damage 

Please Choose Deductible for Comp. & Coll. 

Do you want optional Spousal Liability? 

Do you want optional OBEL (Pedestrian)?  

Do you want Optional Medical Payments?  

Do You want Optional Roadside Assistance?  

Do You want optional Towing?  

            


 

Underwriting & Discount Questions

 

Your Marital Status

 

D0 you have a Motorcycle License?  
Years of Motorcycle Experience?  
Is Motorcycle Kept in locked Garaged?   
Major Tickets/Violations in the last 39 months?

 

Driver Training or Safety Course Certificate?  
Member of Motorcycle Rider Group?  
Are You a Homeowner?  
Do you need a Lien holder listed on Policy  
Is the above Motorcycle Currently Insured?  
 If yes, who  are you insured by?  
What is your current Motorcycle premium?   

 


 

 

Use text box for any questions or comments.

Please list all tickets and violations in last 39 months

Do you want to list an additional operater?

 

 


 

 

It is our goal to provide you with the best coverage at the lowest price from one of top quality insurance companies we represent. We look forward to serving you in the near future. 

How should we contact you? Phone  Fax  E-mail  Regular Mail      
 

Thank you for taking the time to fill out this worksheet. We will use the information you supplied along with your DMV records and your consumer reports which include your credit and financial responsibility information to obtain an insurance quote for you. This information will be kept confidential and is used by us and the insurance companies we represent for rating  purposes only. By submitting this form you are authorizing us to access your information and provide you with a quote.

 

 
Kenneth Veale
 

Ryde Insurance Agency

Ryde Insurance Agency

106 W Broadway

Port Jefferson, New York, 11777

 

 

E-mail: Rydemc@aol.com

E-mail: Ryde Insurance

Phone:631-476-0722

Fax: 631-476-1378

 

 

 


 








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