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Motorcycle Insurance Quote Request
To receive a free motorcyle insurance quote from the Perrine Agency, answer the following questions and submit.  An agent will analyze your information and contact you shortly.  You may also print out this page, fill in at your convenience, and fax to us at (952) 888-1134.

 YOUR INFORMATION
 
  First Name
 
  Middle Name
 
  Last Name
 
  Street Address
 
  City
 
  State
 
  Zip Code
 
  Married or Single?
 
  Phone (Cell) - include area code
 
  Phone (Work) - include area code and extension
 
  Phone (Home) - include area code
 
  Email Address
 
  Date of Birth (month/ day/ year)
 
  Your Drivers License Number
 
  State of Your Current License
 
 VEHICLE INFORMATION / QUESTIONS
 
Yes   No  - Do you currently have motorcycle insurance?
 
Yes   No  - Have you had any accidents, violations or tickets?

  If yes, describe any accidents/ violations or tickets:
  3 year history required - regardless of fault
 
 
 
  Name of Current Insurance Provider (if applic.)
 
  Date Initially Obtained
 
  Reason for Switching to New Insurance
 
  Vehicle Manufacturer (eg Harley, Kawasaki)
 
  Size of Engine (cc - cubic centimeters)
 
  Year of Model
 
  VIN # (Vehicle Idenfitication Number)
 
  # of miles per year driven
 
 Check the following that apply:
 I have taken a certified motorcycle safety class
 Motorcycle has an alarm
 
  DESIRED COVERAGES
 
Check type of policy you would like:
Liability only Full Coverage Not sure
Uninsured & underinsured  
 
Yes   No   -   Additional drivers in household?
 
 If yes, how many additional drivers?  
 
  ADDITIONAL VEHICLE INFORMATION
  
Include Additional Vehicles in Quote?  Yes   No

If no, where are other vehicles insured? 
 
Additional Vehicle 1 Make, Model, Year and VIN:
 
 
Additional Vehicle 2 Make, Model, Year and VIN:
    
 
Additional Vehicle 3 Make, Model, Year and VIN:
 

What is the best time of day to reach you by phone? 

Enter any comments/ questions/ suggestions below:

Click below to submit information.

 

 
 


"Don was able to find us the best package to meet our needs at the best price and provided friendly, personal service.  Glad we found you!"

Kevin & Jill Unterreiner
Eden Prairie, MN