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Application Information
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Name (First, Last):
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Email:
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Confirm Email
Address:
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Address:
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City:
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State:
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Zip:
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Home Phone:
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(Include
area code)
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Work Phone:
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(Include
area code)
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How did you hear about
A&J Insurance Agency:
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Yellow Pages
Referral
Flyer
Direct Mail
Other
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Are you currently
insured?:
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Yes
No
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Current Insurance
Company:
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Policy Expiration Date:
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Years of Continuous
Prior Insurance:
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Number of
Riders:
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Number of
Motorcycles:
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First
Rider Information
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First Name:
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Last Name:
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Relationship to Applicant:
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Birth date:
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Gender:
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Marital Status:
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In Military:
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Yes
No
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Occupation:
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State Licensed:
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Yes
No
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License Ever Suspended?
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Yes
No
If Yes, give date
Date license reinstated.
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SR22 Filing Needed:
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Yes
No
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Accidents
and Violations
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Tickets:
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(within the last 3 years)
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Accidents:
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(within the last 3 years)
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Number of major violations:
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(DUI, HIT &
RUN within the last 5 years)
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Comments:
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CLICK
HERE FOR SECOND RIDER INFORMATION
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Motorcycle information
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Principal
Rider:
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Year:
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Make:
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Model:
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CC:
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Usage:
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Annual Mileage:
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Miles driven to work/school:
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(one
way)
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Anti Theft Alarm:
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Yes
No
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Where is the motorcycle
parked at night?:
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Name of Lease finance Company:
(if None
enter NONE)
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CLICK
HERE FOR SECOND MOTORCYCLE INFORMATION
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Insurance Information
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Coverage:
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AJ Smart
Quote
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Note:
With AJ Smart Quote, you are ensured that you are making the choice of insurance
coverage
fit best for your needs. Choose a package that suits your
requirements.
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Individually choose your coverage types
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Liability Bodily Injury:
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Liability Property Damage:
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Medical Coverage:
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Uninsured Motorists Bodily Injury:
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Uninsured Motorists Property
Damage/Waiver of Collision:
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Yes
No
By
default “3,500/WCD”
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Comprehensive Deductible:
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Collision Deductible:
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Please
Contact me by:
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Mail
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Address:
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City:
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State:
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Zip:
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email
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Email:
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Phone
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Home
Phone:
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Work Phone:
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Other Phone:
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I
am also interested in
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Second
Rider Information
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First Name:
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Last Name:
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Relationship to Applicant:
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Birth date:
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Gender:
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Marital Status:
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In Military:
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Yes
No
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Occupation:
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State Licensed:
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Yes
No
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License Ever Suspended?
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Yes
No
If Yes, give date
Date license reinstated.
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SR22 Filing Needed:
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Yes
No
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Accidents
and Violations
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Tickets:
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(within the last 3 years)
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Accidents:
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(within the last 3 years)
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Number of major violations:
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(DUI, HIT &
RUN within the last 5 years)
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Comments:
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CLICK
HERE TO CONTINUE
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Second
Motorcycle information
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Principal
Rider:
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Year:
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Make:
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Model:
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CC:
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Usage:
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Annual Mileage:
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Miles driven to work/school:
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(one
way)
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Anti Theft Alarm:
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Yes
No
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Where is the motorcycle
parked at night?:
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Name of Lease finance Company:
(if None
enter NONE)
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CLICK
HERE TO CONTINUE
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