Minnesota insurance from Miller Hartwig Insurance Insurance
Meeting the Insurance Needs of Minnesota Residents & Businesses for Decades!
 
Personal Auto, Homeowners Insurance from Miller Hartwig Insurance
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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 Minnesota)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
Were You Referred to an Agent?
If Yes, Whom?
 
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:
Vehicle Identification Number - VIN: # 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:
Vehicle Identification Number - VIN: # 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
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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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Miller Hartwig Insurance . PO Box 1177 . Lakeville, MN 55044
Phone: 1-952-469-0407 | Fax: 1-952-469-1881 | E-Mail us at: quotes@insurance4MN.com
Our Telephone Quoting Hours are: 8:00am to 5:00pm (Mon-Thurs), 8:00am to 3:00pm (Fri)
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