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J L Le Claire & Sons Insurance Agency
The Protection and Security you would expect from Family
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Off Road Vehicle Insurance Quote

Please fill out the form below to receive a quote on Off Road Vehicle 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:
   
Current Carrier:
Current Premium:
   
Vehicle Information:
 
Vehicle 1
Vehicle 2
Vehicle Type
Year
Make and Model
Vin#
CC Size
Current Market Value
Use
Business Personal
Business Personal
Estimated Annual Milage
Number Of Wheels
Dune Buggy?
Yes No
Yes No
If Yes, Chassis Make & Engine Make
Golf Cart?&
Yes No
Yes No
If yes, please indicate power source (gas, electric, diesel)
ATV?
Yes No
Yes No
If Yes, Please Indicate the Number of Wheels
Snowmobile?
Yes No
Yes No
If Yes, Please Indicate the Number of Passengers
Principal Driver:
Full coverage or Liability only:
Vehicle 3
Vehicle 4
Vehicle Type
Year
Make and Model
Vin#
CC Size
Current Market Value
Use
Business Personal
Business Personal
Estimated Annual Milage
Number Of Wheels
Dune Buggy?
Yes No
Yes No
If Yes, Chassis Make & Engine Make
Golf Cart?&
Yes No
Yes No
If yes, please indicate power source (gas, electric, diesel)
ATV?
Yes No
Yes No
If Yes, Please Indicate the Number of Wheels
Snowmobile?
Yes No
Yes No
If Yes, Please Indicate the Number of Passengers
Principal Driver:
Full coverage or Liability only:
Driver 1
Driver 2
Name:
Date of Birth:
Driver's License Number:
Total Years Licensed
Off Road Vehicle Safety Course Date
Marital Status:
Gender:
Male Female
Male Female
Tickets/Accidents?
Yes No
Yes No
Usage - Work/Pleasure:
Driver 3
Driver 4
Name:
Date of Birth:
Driver's License Number:
Total Years Licensed
Off Road Vehicle Safety Course Date
Marital Status:
Gender:
Male Female
Male Female
Tickets/Accidents?
Yes No
Yes No
Usage - Work/Pleasure:
Coverage Information
Medical Payments
Passenger Liability

Transport Trailer Information

Year:
Make:
Model:
Serial Number/VIN:
Value:

Deductible Information

Vehicle 1

Optional Equipment Amount (Does Not Apply to Dune Buggies or Golf Carts, Maximum of $7,500 Per Vehicle):

Vehicle 2

Optional Equipment Amount (Does Not Apply to Dune Buggies or Golf Carts, Maximum of $7,500 Per Vehicle):

Vehicle 3

Optional Equipment Amount (Does Not Apply to Dune Buggies or Golf Carts, Maximum of $7,500 Per Vehicle):

Vehicle 4

Optional Equipment Amount (Does Not Apply to Dune Buggies or Golf Carts, Maximum of $7,500 Per Vehicle):
     
 
Comments/Additional Information:Ticket/Accident dates and details
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