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PERSONAL INFORMATION
Name
Address
City
State
Zip Code
E-Mail
Home Phone
Work Phone
Fax Number
Insured's Social Security Number
Date of Birth and Sex Of All Operators
Do You Have A Motorcycle License?	Choose One Yes No
How Many Years Experience Do You Have Riding Motorcycles?
Where Do You Keep Your Motorcycle When Not Using It?
List Any Accidents Or Violations In The Past 5 Years
Are You A Homeowner?	Choose One Yes No
Are You Married?	Choose One Yes No
Present Insurance Carrier
Expiration Date
MOTORCYCLE COVERAGE INFORMATION
Liability
Medical Payments
Uninsured Motorist - Bodily Injury
Uninsured Motorist - Property Damage
Collision Deductible
Other Than Collision (Comprehensive) Deductible
Year Motorcycle Was Made
Manufacturer
Model
CC's
Do You Have An Alarm?	Choose One Yes No
If Yes, What Type Of Alarm?

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© Copyright 2001-2006 Rotatori Insurance Agency. All rights reserved.
Rotatori Insurance Agency • PO Box R - 1101 Putnam Pike, Chepachet, RI 02814
Tel: 1-800-351-7888 • Fax: 401-568-8007 • E-Mail: info@rotatoriinsurance.com