WHCRA Enrollment Notice - MIBSGA Staging Site

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WHCRA Enrollment Noticeadmin2017-09-20T17:27:25-05:00

WHCRA Enrollment Notice Pre-Populate Form

You will be emailed a copy of the completed form upon completing the fields below

Step 1 of 6

16%

Producer Information
Producer Name*
First Last
Producer Phone Number*
Producer Email*
Enter Email Confirm Email

Insured Personal Information
Requested Effective Date
MM slash DD slash YYYY
Insured's Name
First Last
Phone Number
Insured's Email
Address*
Street Address Address Line 2 City State ZIP Code
Highest Education Completed?*
- High School
- Associate's Degree
- Bachelor's Degree
- Law or Medical Degree
Does the insured own or rent their home?*
- Own
- Rent
Gender*
- Male
- Female
DOB*
Month
Day
Year

Rider Information
Does the rider have motorcycle endorsement added on their drivers license?*
- Yes
- No
Has the rider owned or been insured on a motorcycle within the past 5 years?*
- Yes
- No
How many years?*
MC Safety Foundation Course?*
- Yes
- No
Date course completed:
Member of MC Association?*
- Yes
- No
Name of Association:
Have you had any tickets or accidents within the last 5 years?*
- Yes
- No
Please explain any tickets you have recieved?*
Within the last 5 years, how many calendar years has the rider been operating a motorcycle?*

Vehicle Information
Year*
Make*
Model*
VIN*
CCs*
Cost New / Actual Value*
(if physical damage is requested or cycle is more than 25 years)
Date Purchased*
Month
Day
Year
Is the motorcycle garaged?*
- Yes
- No
Is the Garage address the same as the Rider's address?*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Policy Information
Does the Rider have Current Motorcycle Insurance?*
- Yes
- No
Current Carrier*
Number of Months with Current Carrier*
Expiration Date*
MM slash DD slash YYYY
Premium*

Coverage Limits
Bodily Injury*
Property Damage*
Medical Payments*
UM/IM*
Comprehensive Deductible*
Collision Deductible*
Rental Reimbursement*
Roadside Assistance
UM Property Damage
Custom Parts & Equipment
(includes Safety Apparel)
Has coverage been cancelled or renewed in the past three years?
- Yes
- No
Please provide the reason for canceling or renewing*
Please enter any additional information you may have regarding this quote.

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Contact Info

54 West Seegers Road
Arlington Heights, IL 60005

Phone: 847.427.8000

Fax: 847.640.8011

Email: info@midwestga.com

Web: www.Mibsga.com

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