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Name:
as it appears on your Drivers license
Phone:
Address 1:
Address 2:
City:
State:
Zip:
County
Date of Birth:
E-mail
FAX
Gender
Have you had any tickets or accidents in the last 3 years? Yes  No
If Yes, please describe:
Have you had a DUI or other major violations in the last 7 years? Yes  No
If Yes, please describe:
Year, Make and Model:
Purchase Price: (Example: $52,000)
Year Make and model of vehicles:
List additional operators:
Would you get full coverage? (this covers damage to your motorcycle) or liability (minimum required in Ca)?
Please contact me as soon as possible regarding this matter.

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