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J L Le Claire & Sons Insurance Agency
The Protection and Security you would expect from Family
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Please fill out the form below to receive a quote on Motorcycle Insurance. Please leave blank any fields that you are unsure of, or feel uncomfortable giving out information.

* Required Fields

*Name:
*Address:
*City:
*State:
*Zip Code:
*County:
*Email Address:
Telephone:
Social Security Number:
Date of Birth:
Drivers License Number
State Licensed In 
Marital Status 
 
Gender 
 
Any Tickets/Accidents?
Please Explain.
 
Current Premium:
Current Carrier:
Expiration:
Any Claim or Loss in the past 5 years?
Please Explain.
   
MOTORCYCLE INFORMATION:  
Year:
Make:
Model:
Vin Number:
CC'S
Full Coverage or Liability Only? 
Comprehensive Deductible: 
Are you the only operator?
If not, please provide other operator info in comments section at the bottom of this form. 
 
Collision Deductible:
Approximately how many miles will you drive your motorcycle annually:
Comments/Additional Information: