PENNSYLVANIA MOTORCYCLE APPLICATION

Transcription

1 W N TUSCANO AGENCY 950 Highland Ave. P.O. Box 1027 Greensburg, PA (800) Fax: (724) PENNSYLVANIA MOTORCYCLE APPLICATION BEST RATING A EFFECTIVE DATE EXPIRATION DATE (Must be submitted within five (5) days of the effective date) / MARRIED SINGLE / TERRITORY APPLICANT S NAME TELEPHONE NUMBER AGENCY NAME TELEPHONE # MAILING ADDRESS MAILING ADDRESS CITY COUNTY STATE ZIP CODE CITY STATE ZIP CODE AGENCY CODE # LIENHOLDER LOAN # STREET ADDRESS CITY STATE ZIP CODE Operator #1 NAME DATE OF BIRTH PA DRIVER S LICENSE # (Attach copy) ACCIDENT(S) VIOLATION(S) Operator #2 NOTE: ALL OPERATORS MUST BE LISTED EVEN IF THEY DO NOT LIVE IN THE HOUSEHOLD Cycle #1 YEAR MAKE/MODEL VIN # SIZE (CC S) DATE PURCHASED PURCHASE PRICE Cycle #2 STANDARD PROGRAM / TOUR RIDER PROGRAM / HARLEY PROGRAM / SPECIAL HAZARD / SPORT PROGRAM COVERAGES BODILY INJURY LIMITS 15/30 / 25/50 / 50/100 / 100/300 25,000 PROPERTY DAMAGE LIMIT CYCLE 1 CYCLE 2 IF NO DO NOT SUBMIT Is the motorcycle kept in a locked garage when not in use? Applicable only if physical damage coverage is requested. Do all operators have a Pennsylvania driver s license with the motorcycle endorsement? IF YES DO NOT SUBMIT UNINSURED MOTORISTS LIMIT 15/30 / 25/50 / 50/100 / 100/300 STACKED / UNSTACKED UNDERINSURED MOTORISTS LIMIT 15/30 / 25/50 / 50/100 / 100/300 STACKED / UNSTACKED COMPREHENSIVE AND COLLISION TOUR BIKE ENDORSEMENT SCHEDULED ACCESSORIES List on Back BASIC PREMIUM CREDITS % (MAXIMUM CREDITS 40%) Married Credit 15% Multi Cycle Credit 10% Is any motorcycle chopped, reconstructed (rebuilt), re-titled, nonfactory built or used for exhibition? Is any motorcycle used for racing, hill climbing or for business? Has any operator been convicted of any major violation or had a license suspension / revocation within the past three (3) years? STANDARD PROGRAM: Does any operator have more than three (3) minor violations, any major moving violations, license suspension / revocation or more than one (1) at fault accident in the past three (3) years? TOUR RIDER / HARLEY / SPORT / SPECIAL HAZARD PROGRAM: Does any operator have more than one (1) minor violation, any major moving violations, license suspension / revocation or any at fault accidents in the past three (3) years? NOTE: Major violations are defined on the back of the application. "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties." Transfer / Renewal 20% Applicant s Signature Date MC Driver Training Credit 10% 500 Deductible Credit 10% Producer s Signature Date 1,000 Deductible Credit 15% Preferred Risk Credit 10% DRIVING RECORD SURCHARGE 100% SELECTION OF LOWER UNINSURED MOTORISTS (UM) LIMITS I have been given the opportunity to purchase UM Coverage equal to my Bodily Injury Liability Coverage Limits, but instead, I select lower limits as shown above. TOTAL EACH CYCLE Applicant s Signature Date TOTAL BOTH CYCLES SELECTION OF LOWER UNDERINSURED MOTORISTS (UIM) LIMITS PAY IN FULL 3 PAYMENTS 50% Down / 25% / 25% 4 PAYMENTS 25% Down / 25% / 25% / 25% I have been given the opportunity to purchase UIM Coverage equal to my Bodily Injury Liability Coverage Limits, but instead, I select lower limits as shown above. Applicant s Signature Date

2 INELIGIBLE MOTORCYCLES 1. Motorcycles that are chopped, reconstructed (rebuilt), re-titled, non-factory built or used for exhibition, racing, hill climbs, or business purposes 2. Physical damage coverage on motorcycles with accessories valued at more than 50% of the value of the motorcycle without accessories. 3. Motorcycles that are rented 4. Motorcycles with a value of more than 28,000 (when physical damage is written) 5. Motorcycles with more than two (2) wheels (including ATV and sidecars) except Goldwing conversions and Lehman trikes. 6. Motorcycles that are homemade, kit bikes, go-carts, dune buggies, tractors, cushmans, not produced by original equipment manufacturers, composite or cannot be found in the NADA Motorcycle Appraisal Guide 7. Motorcycles re-powered by engine castings not produced by the motorcycle manufacturer 8. Turbo or other performance enhancements 9. Vehicles co-owned by individuals who do not reside in the same household (excludes finance company) 10. Dirt bikes (off road motorcycles) 11. Any ineligible motorcycle listed on the website: Motorcycles that are not garaged when not in use (applies only when physical damage is requested) 13. Motorcycles titled in a business or trade name MAJOR VIOLATIONS DEFINED Hit and run, careless / reckless driving, driving under the influence of drugs or alcohol, manslaughter, suspended or revoked license, leaving the scene of an accident, driving on the wrong side of the road, speeding 20 mph or more over the speed limit, passing a stopped school bus, any form of speed contest or racing, or evading a peace officer. MINOR VIOLATIONS DEFINED All violations not listed above. STANDARD PROGRAM ELIGIBILITY 1. Operators may not have more than three (3) minor violations, any major violations, a license suspension / revocation or more than one (1) at-fault accident in the past three (3) years. 2. Operators must have a valid motorcycle license. Permits are unacceptable. 3. Operators twenty-two (22) and younger must have completed a Motorcycle TOUR RIDER PROGRAM EIGIBILITY 1. Operators may not have more than one (1) minor violation, any major violations, a license suspension / revocation or any at-fault accidents in the past three (3) years. 2. Operators must have a valid motorcycle license. Permits are unacceptable. 3. Operators twenty-two (22) and younger must have completed a Motorcycle HARLEY PROGRAM ELIGIBILITY 1. Operators may not have more than one (1) minor violation, any major violations, a license suspension / revocation or any at-fault accidents in the past three (3) years. 2. Operators must have a valid motorcycle license. Permits are unacceptable. 3. All operators must have at least one (1) year experience operating a motor cycle 750 cc s or more. A copy of the previous declarations page must be attached. 4. Operators twenty-two (22) and younger must have completed a Motorcycle SPECIAL HAZARD / SPORT PROGRAM ELIGIBILITY 1. May be written with liability coverage only 2. Must be written with minimum liability limits (15/30) only 3. Operators may not have more than one (1) minor violation, any major violations, a license suspension / revocation or any at-fault accidents within the past three (3) years 4. Operator must have a valid motorcycle license. Permits are unacceptable. 5. Operators twenty-two (22) and younger must have completed a Motorcycle INCREASED LIMITS 1. Not available for the Special Hazard / Sport Program. 2. Not available for operators with more than one (1) minor moving violation, any major violations, a license suspension / revocation or any at-fault accidents LIST ACCESSORIES AND NON STANDARD EQUIPMENT Items must be specifically listed for insurance to apply CREDITS MAXIMUM AVAILABLE 40% 15% MARRIED OPERATOR CREDIT Applies if the principal operator of the motorcycle is married 10% MULTI MOTORCYCLE CREDIT Applies if two or more motorcycles are insured with Aegis 20% TRANSFER / RENEWAL CREDIT Applies if a policy has been continuously in effect for a full twelve (12) months prior with Aegis or any other insurer, and if there have been no claims / losses or violations in the past twelve (12) months. A copy of the previous declarations page and / or a copy of the identification card must be attached to the application for the credit to be applied. 10% MOTORCYCLE DRIVER TRAINING CREDIT Applies to all coverages if the principal driver of the motorcycle to be insured provides a copy of either the Certificate of Completion from a Motorcycle Driver Training Course approved by the State Department of Education or the Certificate of Completion bearing the Motorcycle Safety Foundation logo. 10% PREFERRED RISK CREDIT Motorcycle Eligibility: 1. Be the secondary mode of transportation 2. Be garaged when not in use 3. Not be driven back and forth to work or school Operator Eligibility: 1. Be twenty-six (26) years of age or older 2. No more than one (1) minor moving violation 3. No major moving violations, license suspension / revocation or at-fault accidents in the past three (3) years NOTE: The Preferred Risk Credit does not apply to the Tour Rider, Harley and Special Hazard / Sport Programs. IMPORTANT NOTE ABOVE LISTED CREDITS WILL NOT BE APPLIED UNLESS REQUIRED DOCUMENTATION LISTED ABOVE IS ATTACHED TO THE APPLICATION MVR The company will obtain an MVR If the accident and / or violation information given on the front of the application is different than the information found on the MVR, the premium could be increased or if the information makes the risk ineligible, the policy could be null and void or cancelled. DRIVERS LICENSE Coverage is not considered bound unless a clear copy of each operator s drivers license showing the motorcycle endorsement is attached to the application. Permits are unacceptable. ACCIDENT / VIOLATION SURCHARGE 1. One (1) at-fault accident and two (2) minor moving violations 100% 2. Three (3) minor moving violations 100% MOTORCYCLE CLASSIFICATION Refer to the Excel Spreadsheet listing motorcycle classifications on our website: ACCESSORIES There is no coverage for accessories unless they are scheduled. Accessories will not be scheduled unless a description and value for each accessory is provided. CANCELLATION If the insured requests mid-term cancellation, the cancellation will be calculated on a short rate basis and will be subject to the minimum earned premium shown on the declaration page. LIST ACCESSORIES AND NON STANDARD EQUIPMENT Items must be specifically listed for insurance to apply DESCRIPTION VALUE DESCRIPTION VALUE DESCRIPTION VALUE DESCRIPTION VALUE PAMCAPP (1-05)

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