Bicycle Quote Sheet
- 1. Insurance and discounts are subject to availability and qualifications. Consumer notice of insurance scoring: To offer an accurate quote in connection with your application for insurance, we may use a credit-based insurance score developed by a third party based on information contained in the unit owner’s credit report. Furture reports may be used to update or renew insurance. For state-specific notices, please visit www.markelamerican.com/scoringnotice. By submitting this form, applicant acknowledges notification of the disclosure for their state. Insurance is provided by Markel American Insurance Company; Glen Allen, VA. ©2014 Markel Service, Inc. Bicycle Insurance – Quote Sheet Producer Information Agency Name: City: Producer #: Contact Name: Email: Phone #: Policyholder Information Full Name: Email: Date of Birth: Social Security # (optional): Mailing Address: City: State: Zip: Bicycle Information Model Year: Manufacturer: Model Name: Bicycle Type: Road / Track Mountain Hybrid / Cruiser Recumbent BMX Tandem Electric Tricycle Frame Construction: Aluminum Carbon Fiber Steel Titanium Wood Other How is the Bicycle used? (please check all that apply): Casual Commuter Fitness One or more races annually Total Value of Bicycle (including ALL components and accessories): $ Name of Primary Operator: Date of Birth: Do any of the following apply? Primary operator is a professional cyclist Primary operator is a triathlete Primary operator is a member of USA Cycling Primary operator is a member of IMBA Primary operator is a member of USA Triathlon (for additional bicycles and operators, please use page 2) Insurance Coverages and Limits Physical Damage Deductible: No Coverage $100 $200 $300 $500 Bicycle Liability Coverage Limit (combined single limit): No Coverage $25,000 $50,000 Medical Payments Coverage Limit (per person): No Coverage $5,000 $1,000 $7,500 $2,500 $10,000 Vehicle Contact Protection Limit (combined single limit): No Coverage $10,000 $25,000 Worldwide Physical Damage Coverage: Yes No Roadside Assistance Coverage: Yes No Joe Dittemore Ins. Redlands Joe Dittemore [email protected] (909)792-1665
- 2. Insurance and discounts are subject to availability and qualifications. Consumer notice of insurance scoring: To offer an accurate quote in connection with your application for insurance, we may use a credit-based insurance score developed by a third party based on information contained in the unit owner’s credit report. Furture reports may be used to update or renew insurance. For state-specific notices, please visit www.markelamerican.com/scoringnotice. By submitting this form, applicant acknowledges notification of the disclosure for their state. Insurance is provided by Markel American Insurance Company; Glen Allen, VA. ©2014 Markel Service, Inc. Additional Bicycle Information Model Year: Manufacturer: Model Name: Bicycle Type: Road / Track Mountain Hybrid / Cruiser Recumbent BMX Tandem Electric Tricycle Frame Construction: Aluminum Carbon Fiber Steel Titanium Wood Other How is the Bicycle used? (please check all that apply): Casual Commuter Fitness One or more races annually Total Value of Bicycle (including ALL components and accessories): $ Name of Primary Operator: Date of Birth: Do any of the following apply? Primary operator is a professional cyclist Primary operator is a triathlete Primary operator is a member of USA Cycling Primary operator is a member of IMBA Primary operator is a member of USA Triathlon Additional Bicycle Information Model Year: Manufacturer: Model Name: Bicycle Type: Road / Track Mountain Hybrid / Cruiser Recumbent BMX Tandem Electric Tricycle Frame Construction: Aluminum Carbon Fiber Steel Titanium Wood Other How is the Bicycle used? (please check all that apply): Casual Commuter Fitness One or more races annually Total Value of Bicycle (including ALL components and accessories): $ Name of Primary Operator: Date of Birth: Do any of the following apply? Primary operator is a professional cyclist Primary operator is a triathlete Primary operator is a member of USA Cycling Primary operator is a member of IMBA Primary operator is a member of USA Triathlon