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  • LINK TO HOME PAGE

     
    E-Mail:
    glamb@farmersagent.com

    Local Phone:
    281-537-2700

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  •  
    Online Motorcycle
    Insurance Quote Form
    One Simple Form - takes only 2-3 Minutes!


    YOUR PERSONAL DATA:

    Your Name:
    Street Address:
    City:
    State: MUST be Texas!
    Zip/Postal:
    E-Mail (REQUIRED):
    E-Mail again for accuracy:
    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 violations within
    last 3 years:
    Number & Type of
    MAJOR violations 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 violations within
    last 3 years:
    Number & Type of
    MAJOR violations 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


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    Lamb Insurance Agency (Farmers Insurance)  |  28 FM 1960 West, Houston, TX 77090
    Phone: 281-537-2700   Fax: 281-537-8502   Cell: 281-881-5756