Florida Motorcycle Insurance Quote - low cost coverage and high priced service!

Vista Healthplan, Inc.

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© 2004 J.A. MESSINA INSURANCE
PO Box 244571
Boynton Beach, FL 33424-4571
Phone: 561-736-2162
Fax: 561-736-0228
License#A177282
E-Mail us at:
jamessinains@comcast.net

For Your Convenience,
We gladly accept:

"All Our Policies Come With
an Agent!"

Need Coverage TODAY? After Submitting
Your Quote Form (see below), Call Toll-Free:
1-800-735-2162
(Monday-Friday 9:00am-5:00pm Florida local time)

On-Line Motorcycle
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!

YOUR PERSONAL DATA:

Your Name:

Street Address:

City:

State: MUST be Florida!

Zip/Postal:

E-Mail (REQUIRED):

Phone:

Fax (optional):

Marital Status:
Single Married
Homeowner?
Yes No

Currently Insured?
(If yes, list carrier, and # of years
continuous. If no, type NONE)

DRIVER INFORMATION #1

Name: Birthdate:

Sex: # Years U.S.
Auto License:

Cycle Safety Course? # Years U.S.
Cycle License:

Number & Type of
Accidents within
last 3 years: Number & Type of
MINOR Cites within
last 3 years:

Number & Type of
MAJOR Cites within
last 3 years: Daily commute
in ONE WAY miles:

Does Driver need
an SR22 FILING? Yes No Comments or
Remarks?

DRIVER INFORMATION #2 (if none, leave blank)

Name: Birthdate:

Sex: # Years U.S.
Auto License:

Cycle Safety Course? # Years U.S.
Cycle License:

Number & Type of
Accidents within
last 3 years: Number & Type of
MINOR Cites within
last 3 years:

Number & Type of
MAJOR Cites within
last 3 years: Daily commute
in ONE WAY miles:

Does Driver need
an SR22 FILING? Yes No Comments or
Remarks?

VEHICLE #1 INFORMATION

Year of vehicle: Make & Model:

Is this a 4 Wheeler?: If Yes, Describe:

Annual Mileage: # of CC's:

Value of Bike: $ Special Equipment Value: $

VEHICLE #1 COVERAGES:

Limits of
Liability: $15/30 BI / 10 PD
$25/50 BI / 15 PD
$50/100 BI / 50 PD
$100/300 BI / 50 PD

Comprehensive
& Collision: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Do you want
Medical Coverage? Yes No   Uninsured
  Motorists Cov.? Yes No

VEHICLE #2 INFORMATION (if none, leave blank)

Year of vehicle: Make & Model:

Is this a 4 Wheeler?: If Yes, Describe:

Annual Mileage: # of CC's:

Value of Bike: $ Special Equipment Value: $

VEHICLE #2 COVERAGES:

Limits of
Liability: $15/30 BI / 10 PD
$25/50 BI / 15 PD
$50/100 BI / 50 PD
$100/300 BI / 50 PD

Comprehensive
& Collision: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Do you want
Medical Coverage? Yes No   Uninsured
  Motorists Cov.? Yes No

Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone

Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Motorcycle Quote NOW!

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