POINT OF SALE PHYSICAL DAMAGE INSURANCE ORDERING PROCEDURES

POS Insurance coverage is available for all Retail Dealers and Lenders who sell/finance motorcycles and Watercraft. The Pos Insurance Program issues a monthly billed six (6) monthly physical damage policy.

First Name:

Last Name:

Address:

City:

State:

Zip:

Telephone:

Email Address:

Date Of Birth (mm/dd/yyyy):

Driver's License #:

How many MINOR violations within the last 3 years?

Type:

Date:

Type:

Date:

Type:

Date:

How many MAJOR violations within the last 3 years?

Type:

Date:

Type:

Date:

Type:

Date:

List All Vehicles On Policy:

Vehicle Make:

Model:

Year:

Vehicle Make:

Model:

Year:

Vehicle Make:

Model:

Year:

Physical Deductibles:

Select One... 250 500 1000

Bodily Injury Liability:

Select One... 15/30 25/50 100/300

Do You Currently Have Insurance?

Yes

No

Who Do You Have Insurance With?

How Much Are Your Monthly Payments?

When Does Your Current Policy Expire?

Why Are You Shopping For Auto Insurance Today? Please add any additional comments or questions you wish to have answered by one of our representatives