Contact Information

Name
Street Address
City
State
Zip Code
County
Daytime Phone
Evening Phone
Fax
E-Mail address
Are you currently insured?	Yes No
If currently insured, by what company?
Policy Expiration Date

Driver Information

Name
Date of Birth
Marital Status	Married Single Divorced Widow(er)
Gender	Male Female
# of Years Licensed to Drive
Drivers License Number
# of Years Motorcycle Experience
# of Tickets in last 3.5 years	None 1 2 3+
# of Accidents (regardless of fault) in last 3.5 years	None 1 2 3+
Please give details regarding the tickets or accidents:

Motorcycle Information

Year
Make (ex - Harley-Davidson)
Model (ex - Sportster)
Engine Size (cc's)
Current Value ($'s)
Safety Features (Select all that apply): Alarm System Anti-lock Brakes
Is there a lien (loan) on this motorcycle?	Yes No

Coverage Information

Comprehensive Deductible None $50 $100 $200 $250 $500 $1,000

Collision Deductible None $50 $100 $200 $250 $500 $1,000

Liability Coverages
Liability Coverage Minimum 25/50 50/100 100/300 250/500 300csl 500csl	Property Damage Minimum $10,000 $25,000 $50,000 $100,000	Uninsured Motorist Minimum 25/50 50/100 100/300 250/500 None

Other types of insurance you have (check all that apply): Home Life Disability Long-term Care Business Auto Umbrella Business Flood Auto Boat

Additional information, comments or questions:

Home

McKenzie Agency, Inc.
1315 N. County Road West
Odessa, Texas 79763

(432) 333-3532
(800) 395-3532 (tollfree)
e-mail: info@mckenzieins.com