Phillip R Davis & Associates

Physical address:
Phillip R Davis & Assoc Inc.
1623 W Centre Ave
Portage Mi. 49024

Mailing address:
Phillip R Davis & Assoc Inc.
P.O. Box 1836
Portage Mi. 49081-1836

Agency: 269.327.1622

Toll Free: 800.642.4431

Fax: 269.327.1673

prdavis@tds.net

Ashley Gibney

269.492.3156
Email Ashley

Melanie Littell

269.492.3157
Email Melanie

Nancy Nap

269.492.3158
Email Nancy

Michelle Clark

269.327.1622
Email Michelle

Motorcycle/Boat Insurance Quote Form

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. Information submitted will be held confidential and will be used for quote purposes only.

Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Personal Information *Indicates a required field
*Full name:
*E-mail:
*Daytime phone:
Evening phone:
Fax:
How would you prefer to be contacted regarding your quote?			Phone Fax Mail Email
If you prefer to be contacted via phone, please let us know the best time to call.			AM PM
Address:
City:
State:
*Zip:
County:
Township:
Do you currently own your home or rent?	Own Rent
Driver's License Number::
Driver Information Driver #1
Name:
Date of birth:		mm/dd/yyyy
Marital status:		Married Single
Has Driver #1 had a ticket or accident in the last 5 years?						Yes No
Has Driver #1 been convicted of a felony in the last 5 years?						Yes No
Does Driver #1 have health insurance through an employer that covers vehicle use?						Yes No
Driver #2
Name:
Date of birth:					mm/dd/yyyy
Marital status:					Married Single
Has Driver #1 had a ticket or accident in the last 5 years?					Yes No
Has Driver #1 been convicted of a felony in the last 5 years?					Yes No
Does Driver #1 have health insurance through an employer that covers vehicle use?					Yes No
Driver #3
Name:
Date of birth:					mm/dd/yyyy
Marital status:					Married Single
Has Driver #1 had a ticket or accident in the last 5 years?					Yes No
Has Driver #1 been convicted of a felony in the last 5 years?					Yes No
Does Driver #1 have health insurance through an employer that covers vehicle use?					Yes No
Motorcycles Bike #1
Safety course?					Yes No
Years of cycle experience:
Year:
Make:
Model:
CCs:
Vehicle ID# (VIN):
Assembled bike?					Yes No
Value:					$
Extra equipment value:					$
Alarm?					Yes No
Full coverage?					Yes No
Deductible Comprehensive & Collision:					$200 $500
Current cycle insurance?					Yes No
If "Yes," how long?					months
If "Yes," with what company?
Requested Bodliy Injury Limits:					50,000-100,000 100,000-300,000 250,000-500,000 500,000-500,000
Bike #2
Safety course?					Yes No
Years of cycle experience:
Year:
Make:
Model:
CCs:
Vehicle ID# (VIN):
Assembled bike?					Yes No
Value:					$
Extra equipment value:					$
Alarm?					Yes No
Full coverage?					Yes No
Deductible Comprehensive & Collision:					$200 $500
Current cycle insurance?					Yes No
If "Yes," how long?					months
If "Yes," with what company?
Requested Bodliy Injury Limits:					50,000-100,000 100,000-300,000 250,000-500,000 500,000-500,000
Boat
Year:
Make:
Model:
Hull construction:
Engine type:					Inboard Outboard Inboard/Outboard
Horsepower:					HP
Top speed:					Knots
Boat length:					feet
Value of boat:					$
Value of engine:					$
Value of trailer:					$
Extra equipment value:					$
Waters navigated:					Inland lakes Great Lakes Ocean
Years of boating experience:
Safety course?					Yes No
Questions, comments, or additional information:

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