Motorcycle Discount Submission Form

We’ll send you our email address to forward copies of your motorcycle class completion certificate, receipt, and insurance declarations page. Upon receipt of the copies, we’ll send you a check!

Did you successfully complete a basic motorcycle instruction class? *

Yes

No

Did you successfully complete a motorcycle instruction class other than a basic class? *

Yes

No

Did you purchase motorcycle insurance with at least $250,000 underinsured coverage? *

Yes

No

Do you have any questions or need help to purchase $250,000 underinsured coverage? (We can answer questions but do not sell insurance) *

Yes

No

Do you live in Manhattan, Bronx, Brooklyn, Staten Island, Queens, Nassau or Suffolk to qualify for your discount? *

Yes

No

First Name *

Last Name *

Phone Number *

Email *

Address *

Address

Address

Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

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Country

Date Of Birth *

Message *

Number

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Your date of birth is required only so that we can mail you a birthday card. By filling out this form, you agree that we can send you emails.