Office  Hours: M-F  9am to 5pm
670 E 32nd St. Suite 12
  Yuma, AZ   85365    
Call today: (928) 317 1212

           CCalifornia- Golf Cart & ATV Quoting Information

              Please provide as much information as possible within the application below for the most accurate quotes available.
             Upon completion of this information, hit "submit" once and the form will be sent to a representative for quoting. The information provided will be quoted among the multiple insurance carriers our office proudly represents. A representative will respond with the quotes via the contact option selected, normally in 1 business day or less.

                      Thank you for your time and we look forward to assisting you!



 

 

 

 

 

 

 

 



























 

 

 


 

 


















 





  























































 


Primary Insureds Information
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
State:
Zip Code: (5 digits)
Mailing Address:
Phone # 1:
Phone # 2:
E-mail:
Preferred Contact:
Date of Birth:
Drivers License Status:
Drivers Licensed Issued in...:
Motorcycle Endorsment on License:
Marital Status:

Other Household Members/Drivers
Please list all household members of driving age. Select if this person will be listed as a "Rated Driver" or if they will be "Excluded" from coverage.
Household Member/Driver     
 #2- First Name:
        Last Name:
Relationship to Primary Insured:
Household Member/Driver     
 #3- First Name:
        Last Name:
Relationship to Primary Insured:
Are there any other household drivers to list?:
Will any of the Household Members be Excluded from Coverage?:
Has any driver taken a Rider Safety Course in the last 3 yrs?:

Motor Vehicle Report/History
Has a listed driver had a suspended license in the past 5 yrs?:
Is an SR-22 needed for any listed driver?:
*SR-22 for what State:
Any driver with accidents or violations in the past 3 years?:
*Please select incident from list- Incident # 1:
Next driver with accident or violation in the past 3 years?:
Incident # 2:
Next driver with accident or violation in the past 3 years?:
Incident # 3:
Comments:
I authorize verification of my Motor Vehicle and credit history:

Coverage Information
Select All Requested Coverages For Quoting. *Option Listed Under "Vehicle Information" To Designate Coverages Per Vehicle.
Liability Limits:
Uninsured and Underinsured Motorist Coverage:
Medical Payments:
Comprehensive Deductible:
Collision Deductible:
Trailer Coverage:



Vehicle # 1 Information
Vehicle Identification Number (V.I.N)
( if available ):


Or Enter Vehicle Specifications-
Year:
Make:
Model:
CC size:
Value/Purchase Price:
Ownership Information:
How many wheels are on vehicle?:
Will the vehicle be Licensed for On/Off Road Use?:
Has the vehicle been modified, turbo or supercharged or built from a kit?:
Does the vehicle have a Salvaged Title?:

Vehicle # 2 Information
Vehicle Identification Number (V.I.N)
( if available ):


Or Enter Vehicle Specifications-
Year:
Make:
Model:
CC size:
Value/Purchase Price:
Ownership Information:
How many wheels are on vehicle?:
Will the vehicle be Licensed for On/Off Road Use?:
Has the vehicle been modified, turbo or supercharged or built from a kit?:
Does the vehicle have a Salvaged Title?:

Discount Questions ( if applicable )
Is vehicle stored in an enclosed structure, such as a garage or shed?:
Current/Previous Insurance Coverage Information:
Current/Previous Insurance Carrier ( if applicable ):
Residency Status:
Alarm:
Are you a member of any type of riders association or group?:
Years of Operating/Riders Experience: