New California Law
Effective January 1st.
2005
Did you know that if
you allow your
insurance to cancel the
DMV will cancel your
vehicle registration?
Insure your vehicles
Today!
First Name:
Last Name:
Home Phone:
Work Phone:
EXT.
Cell Phone:
E-Mail Address:
Garaging Address:
Mailing Address:
Driver Information
Driver # 1
(Note! Named Insured)
NOTE! Skip additional driver
information if no more drivers.
First Name:
Last Name:
Birth Date:
Sex:
Male
Female
Marital Status:
Single
Married
Prior Insurance:
None
6 Months
12 Months-1 Year
18 Months
24 Months-2 Years
30 Months
36 Months-3 Years
42 Months
48 Months-4 Years
54 Months
60 Months-5 Years
Exp. Date:
Licensed
Yrs
California
:
California Driver License #:
Verifiable U.S.:
Verifiable Cycle:
International:
Violations
(past three years)
SR Filling:
Driver # 2
First Name:
Last Name:
Birth Date:
Sex:
Male
Female
Marital Status:
Single
Married
Prior Insurance:
None
6 Months
12 Months-1 Year
18 Months
24 Months-2 Years
30 Months
36 Months-3 Years
42 Months
48 Months-4 Years
54 Months
60 Months-5 Years
Licensed
Yrs
California:
California Driver License #:
Verifiable U.S.:
Verifiable Cycle:
International:
Violations
(past three years)
SR Filling:
Motorcycle Informations
Motorcycle Year Make Model Vin.# CCs
Motorcycle #1:
Liability Limits
-Bodily Injury,
Property Damage covers losses
to the other party if you are at
fault.
Motorcycle #2:
Coverages
Medical Payments
-Apply to
the named insured and his/her
passengers.
Uninsured Motorist
Protraction
- Applies to the
insured in case of an uninsured
motorist causes loss to
you/your vehicle and they are
at fault.
Bodily Injury:
15/30
25/50
50/50
30/60
25/100
50/100
100/100
100/300
300/300
250/500
Note! If more than one Motorcycle,
same coverages apply for Bodily
Injury, Property Damage, Medical
Payments and Uninsured Motorist.
Property Damage:
5
10
15
25
50
60
100
250
Medical Payments:
0
1
2
3
4
5
Uninsured Motorist Bodily:
None
15/30
20/40
25/50
Uninsured Motorist Property:
None
3,500
Motorcycle #1
Motorcycle #2
Comprehensive
-Theft,
Vandalism, and any accidents
which doesn't involve other
objects.
Comprehensive
-Accident
which involves other vehicles
and objects.
Comprehensive:
None
100
200
250
500
1000
None
100
200
250
500
1000
Collision:
None
100
200
250
500
1000
None
100
200
250
500
1000
Towing:
I
I
I
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