Motorcycle Insurance

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Cooperstown Financial Services LLC

Scott Curtis 99 Chestnut Street

Cooperstown, NY 13326

Phone: 607.322.4032

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Fax: 607.322.4032

www.cooperstownfinancial.com

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s.curtis@cambridgesecure.com

Securities offered through Registered Representatives of Cambridge Investment Research, Inc., a broker-dealer member FINRA/SIPC. Advisory services through Cambridge Investment Research Advisors, Inc., a Registered Investment Adviser. Cambridge and Cooperstown Financial Services, LLC are not affiliated.

Financial Professionals may only conduct business with residents of the states or jurisdictions in which they are properly registered, licensed or exempt from registration and not all of the securities, products and services mentioned are available in every state or jurisdiction.

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Driver #1 Information
Name:
Age:
Marital Status:
List all citations received in the past 3 years (Please include non-moving violations).
List all accidents that were your fault.
List all accidents that were NOT your fault.

Motorcycle #1 Information
Year:
Make:
Model:
Body Style:
Engine CC's:
List any club membership, Goldwing, etc.
Have you taken a motorcycle safety course?
Select Coverage and Limits Below
	Liability
Liability Limits:
	Un(der)insured Motorist - Will Match Liability Selection
	Medical/Personal Injury Protection - Will Match Liability Selection
	Comprehensive
Comprehensive Deductible:
	Collision
Collision Deductible:
Please use the space below to add comments regarding any special circumstances or coverage needs.


Driver #2 Information
Name:
Age:
Marital Status:
List all citations received in the past 3 years (Please include non-moving violations).
List all accidents that were your fault.
List all accidents that were NOT your fault.

Motorcycle #2 Information
Year:
Make:
Model:
Body Style:
Engine CC's:
List any club membership, Goldwing, etc.
Have you taken a motorcycle safety course?
Select Coverage and Limits Below
	Liability
Liability Limits:
	Un(der)insured Motorist - Will Match Liability
	Medical/Personal Injury Protection
	Comprehensive
Comprehensive Deductible:
	Collision
Collision Deductible:
Please use the space below ot add comments regarding any special circumstances or coverage needs.