Motorcycle Insurance Quote - Laura Harris Agency Inc. of Texas

Accidents & Violations

General Information

Laura Harris Agency Inc.
Professional Service

5350 S Staples St Suite 150
Corpus Christi, TX 78411
361-985-2875
361-985-0509 (fax)

email:dawneperez@allstate.com

Our agency is licensed to quote and write insurance policies only in Texas. To find agents offering these coverages in all other states, please click the IQ.net logo.


Motorcycle Insurance Quote
Completely fill out and submit this form to our agency to receive an accurate quote. You MUST provide at least one method of contact to receive a quote from our agency.

General Information

Name: (required)

email Address: (required)

Street:

City: (required)

County:

State:(required) Zip: (required)

Day Phone:

Evening Phone:

FAX:

Name Date of Birth Sex Married/Single M/C Exp

Rider #1

Rider #2

Rider #3

In order to provide a PREFERRED policy quote some of the companies that we represent may require a credit and/or claims history. For Preferred quotes, Social Security numbers are required. You do not have to provide social security numbers at this time but we can't guarantee that we can provide the best price available until after we speak with you and secure this credit and/or claim information.

Check this box to grant our agency permission to secure your credit and/or claim history, for insurance purposes only, under the Fair Credit Reporting Act. Your name

We need to know about your cycles.
All of this information is required to receive a quotation

Year Make Model Eng Size (CC) Value ($)

Cycle #1

Cycle #2

Cycle #3

Motorcycle Insurance Coverage
Desired Coverage Liability only Liability/Comp Full Coverage

Liab Limits Deductible Uninsured
Motorists Passenger
Liability

Cycle 1

Cycle 2

Cycle 3

Accidents & Violations

Last 3 Yrs (Minors)
Last 5 Yrs (Majors) Driver 1 Driver 2 Driver 3 Driver 4

Minor Violations - Speeding, Illegal Turn, Stop Sign, Red Light, etc. (Within the last 3 years)

Accidents - Non Chargeable (Within the last 5 years)

Accidents - Chargeable (Within the last 5 years)

General Information
Name: (required)
email Address: (required)
Street:
City: (required)
County:
State:(required)	Zip: (required)
Day Phone:
Evening Phone:
FAX:

The following information is optional, but if given we will be able to provide you with a more accurate premium quotation.
Drivers' Information:

Driver #	License Number
1
2
3


Motorcycle Identification Numbers

Veh #1

Veh #2

Veh #3

Please use this area to give us any additional information that you may feel is important for your insurance.

**Motorcycle Identification Numbers**
Veh #1
Veh #2
Veh #3

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Page Created 4-29-02


Latest Revision

Desired Coverage Liability only Liability/Comp Full Coverage
	Liab Limits	Deductible	Uninsured Motorists	Passenger Liability
Cycle 1
Cycle 2
Cycle 3

Accidents & Violations
Last 3 Yrs (Minors) Last 5 Yrs (Majors)	Driver 1	Driver 2	Driver 3	Driver 4
Minor Violations - Speeding, Illegal Turn, Stop Sign, Red Light, etc. (Within the last 3 years)
Accidents - Non Chargeable (Within the last 5 years)
Accidents - Chargeable (Within the last 5 years)

We need to know about your cycles.
All of this information is required to receive a quotation
	Year	Make	Model	Eng Size (CC)	Value ($)
Cycle #1
Cycle #2
Cycle #3

Date of Birth

Married/Single