Champion Insurance Assoc, Inc

Rider's Profile

First Name:

Last Name:

Email:

Contact Phone:

Gender:

Date of Birth:

Marital Status:

What date can coverage start?

Household Information

Do you Own or Rent your primary residence?

Address:

Apt/Unit #:

City:

State:

Have you lived here at least 2 years?

Yes
No

Does your vehicle primarily reside at this address?

Additional Profile Information

Do you belong to any of these cycle/rider organizations or groups?

Have you completed a riding safety course in the last 3 years?

Yes
No

Do you have a valid driver's license from the United States or Canada?

Yes
No

If yes, Please provide your Drivers License Number:

Have you lived here at least 2 years?

Yes
No

If yes, Please provide your Drivers License Number:

Accidents

How many auto, motorcycle or off-road vehicle accidents have you had in the last 3 years?

Please select type of first accident:

Were You at fault?

Yes
No

Date of first accident:

Please select type of second accident:

Were You at fault?

Yes
No

Date of second accident:

Please select type of first accident:

Were You at fault?

Yes
No

Date of first accident:

Please select type of second accident:

Were You at fault?

Yes
No

Date of second accident:

Please select type of third accident:

Were You at fault?

Yes
No

Date of third accident:

Please select type of first accident:

Were You at fault?

Yes
No

Date of first accident:

Please select type of second accident:

Were You at fault?

Yes
No

Date of second accident:

Please select type of third accident:

Were You at fault?

Yes
No

Date of third accident:

Please select type of fourth accident:

Were You at fault?

Yes
No

Date of fourth accident:

Violations

How many auto, motorcycle or off-road vehicle violations have you had in the last 3 years or DUIs in the last 10 years?

Please select type of first violation:

Date of first violation:

Please select type of second violation:

Date of second violation:

Please select type of first violation:

Date of first violation:

Please select type of second violation:

Date of second violation:

Please select type of third violation:

Date of third violation:

Please select type of first violation:

Date of first violation:

Please select type of second violation:

Date of second violation:

Please select type of third violation:

Date of third violation:

Please select type of fourth violation:

Date of fourth violation:

Vehicle Information

Vehicle Type:

Vehicle Make:

Vehicle Model:

Vehicle Year:

Number of wheels:

Annual Miles Driven:

Current Odometer Reading:

Ownership Status?

Additional Riders

Will there be any additional Riders? (When adding other riders, please only list those who ride the vehicles on a regular basis. Any riders you list must legally be able to operate a motorcycle or off-road vehicle.)

First Name:

Last Name:

Gender:

Date of Birth:

Relationship:

First Name:

Last Name:

Gender:

Date of Birth:

Relationship:

First Name:

Last Name:

Gender:

Date of Birth:

Relationship:

First Name:

Last Name:

Gender:

Date of Birth:

Relationship:

First Name:

Last Name:

Gender:

Date of Birth:

Relationship:

First Name:

Last Name:

Gender:

Date of Birth:

Relationship:

First Name:

Last Name:

Gender:

Date of Birth:

Relationship:

First Name:

Last Name:

Gender:

Date of Birth:

Relationship:

First Name:

Last Name:

Gender:

Date of Birth:

Relationship:

Any information you share with us is secure. It will not be sold or reused.

Motorcycle Insurance Wizard

Household Information

Additional Profile Information

Accidents

Violations

Vehicle Information

Additional Riders

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