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January 23, 2021
ABOUT PINECREST INSURANCE
OUR CARRIERS
INSURANCE PRODUCTS
Personal
Homeowner
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Earthquake
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Auto
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Condo
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Renters
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Mobile Home
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Landlord Property
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Personal Umbrella
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Recreational Vehicle
Motorcycle/ATV
Free Online Quote
Boat/PWC
Free Online Quote
RV
Free Online Quote
Commerical
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FREE ONLINE QUOTES
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Home
Earthquake
Auto
Condominium
Renters
Mobile Home
Landlord Property
Personal Umbrella
Recreational Vehicle Quotes
Motorcycle/ATV
Boat/PWC
RV
Business Quote
CLAIMS REPORTING
CONTACT US
Boat/PWC Quote
How Did You Hear About Us?
How Did You Hear About Us? *
Select One
Referral
Web Search
Existing Customer
Other
?
Insured Information
First Name *
Middle Initial
Last Name *
Name Suffix
None
Sr.
Jr.
I
II
III
Home Phone
Work Phone
Cell Phone
Email *
Preferred Contact
Select One
Home Phone
Work Phone
Cell Phone
Email
Mailing Address *
City *
State
California
Zip Code *
Primary Residence (If "Other" is selected, please explain)
Select One
Own House/Condo
Own Manufactured/Mobile Home: 10 yrs or newer
Rent
Live with Parents
Other
Insured moved in last 60 Days? *
Yes
No
Prior Mailing Address (Required if answered "Yes" to previous question)
Current Insurance
Do you presently have Auto Insurance?
Yes
No
Company Name
Renewal Date
Annual Premium
Have you been cancelled or non-renewed in the past three years? *
Yes
No
?
Vehicle(s) Information
Vehicle Type *
Select One
Motorcycle/Trike
ATV
Dirt Bike
Moped/Scooter
?
Do you have the Vehicle Identification Number (VIN)/Serial Number (If "Yes", please enter the number) *
Yes
No
?
Year *
Make *
Model *
Engine CC Size
?
Vehicle Modifications *
None
Turbo or Nitrous Oxide Kit
Modified Frame
?
Zip Code for the Primary Location for your vehicle. *
?
Vehicle Use *
Select One
Pleasure
Commute To/From Work or School
Off-Road
Racing/Commercial UNACCEPTABLE
?
Annual Mileage *
?
If Commute is selected, enter # of miles one way to work/school.
If Commute is selected, enter # of commute days per week
Do you have a 2nd Vehicle? *
Yes
No
Vehicle Type
Select One
Motorcycle/Trike
ATV
Dirt Bike
Moped/Scooter
?
Do you have the Vehicle Identification Number (VIN)/Serial Number (If yes, please enter the number)
Yes
No
?
Year
Make
Model
Engine CC Size
?
Vehicle Modifications
None
Turbo or Nitrous Oxide Kit
Modified Frame
?
Zip Code for the Primary Location for your vehicle
?
Vehicle Use
Select One
Pleasure
Commute To/From Work or School
Off-Road
Racing/Commercial UNACCEPTABLE
?
Annual Mileage
?
If Commute is selected, enter # of miles one way to work/school.
If Commute is selected, enter # of commute days per week
Drivers
First Name *
Middle Name *
Last Name *
Suffix
None
Sr.
Jr.
I
II
III
Birth Date
Gender *
Male
Female
Marital Status *
Select One
Single
Married
Separated
Widowed
Divorced
Relationaship to Insured *
Insured
Driver's License Status *
Valid
Permit
Suspended
Not Licensed
?
Valid Motorcycle License/Endorsement? *
Yes
No
?
Motorcycle License/Endorsement Date (Required if answered "Yes" to previous question)
Does driver require an SR-22 filing? *
Yes
No
?
Approved Safety Course Completion in past three years? *
Yes
No
?
Mature Driver Course completion? *
Yes
No
?
How many years have you been licensed to drive an automobile? *
What is the total number of years driving experience you have had as a licensed motorcyclist? *
?
Belong to a motorcycle association?
None
AAA Roadside Member
American Motorcyclist Assoc
Harley Owners Group
?
Do you have a 2nd Driver?
Yes
No
First Name
Middle Name
Last Name
Suffix
None
Sr.
Jr.
I
II
III
Birth Date
Gender
Male
Female
Marital Status
Select One
Single
Married
Widowed
Separated
Divorced
Relationship to Insured (If "Other" is selected, please explain)
Select One
Spouse
Child
Parent
Other
Driver license status
Valid
Permit
Suspended
Not Licensed
?
Valid Motorcycle License/Endorsement?
Yes
No
?
Motorcycle License/Endoresment Date (Required if answered "Yes" to previous question)
Does driver require an SR-22 filing?
Yes
No
?
Approved Safety Course completion in past three years?
Yes
No
?
Mature Driver Course completion?
Yes
No
?
How many years have you been licensed to drive an automobile?
What is the total number of years driving experience you have had as a licensed motorcyclist?
?
Belong to a motorcycle association?
None
AAA Roadside Member
American Motorcyclist Assoc
Harley Owner Group
?
Accidents, Violations, and Claims
Please provide all accidents, violations, and comprehensive claims, regardless of fault, that occurred in the last three years. Also include all Driving Under the Influence violations that occurred on or after 1/1/01. Please include Incident along with Incident Date.
Incident Type
?
Incident Date
1.
2.
3.
4.
5.
Other Drivers
Please provide the names and birthdates of any other residents in your household licensed to drive.
Name
Birth Date
Do any drivers belong to a Boat/PWC association?
?
1.
None
USCG Auxiliary
US Power Squadron
2.
None
USCG Auxiliary
US Power Squadron
3.
None
USCG Auxiliary
US Power Squadron
4.
None
USCG Auxiliary
US Power Squadron
5.
None
USCG Auxiliary
US Power Squadron
Coverages
Bodily Injury Liability
Select One
No Coverage
50/100
100/300
250/500
Property Damage Liability
Select One
No Coverage
25,000
50,000
100,000
Medical Payments
Select One
No Coverage
1,000
2,500
5,000
Uninsured Motorist Liability
Select One
No Coverage
50/100
100/300
250/500
Uninsured Motorist Property
Select One
No Coverage
25,000
50,000
100,000
Underinsured Motorist Liability
Select One
No Coverage
50/100
100/300
250/500
Underinsured Motorist Property
Select One
No Coverage
25,000
50,000
100,000
Comprehensive Deductible
Select One
No Coverage
250
500
1,000
Collision Deductible
Select One
No Coverage
250
500
1,000
Towing & Labor
Yes
No
Vehicle(s) Information
Hull Material
Fiberglass
Aluminum
Inflatable
Wood (Unacceptable)
Steel (Unacceptable)
Other (Unacceptable)
?
Number of Motors
?
Total Horsepower
?
Propulsion Type
None
Outboard
Inboard/Outboard
Inboard
Jet
Power
Non-power
?
Does the boat have an exposed engine?
Yes
No
?
Modified For Enhanced Performance?
Yes
No
?
Maximum speed
?
Would you like to insure your trailer selections?
Yes
No
?
Market Value of Watercraft
What should I include?)
?
Does the value include a trailer?
Yes
No
?
Original Owner
Yes
No
?
Storage/Mooring ZIP code
?
Is Boat/PWC kept at your place of residence? *
Question is for marketing or research purposes only. It will not affect your rate
Yes
No
Select location at your place of residence
Question is for marketing or research purposes only. It will not affect your rate
Garage
Driveway
Yard
In-Water
Lift
Parking Lot
Other
Boat/Pwc Use
Pleasure Use Exclusively
Racing/Speed Contests – Sail Only
Business/Commercial Use (Unacceptable)
Rented or Leased to Others (Unaccpetable) Live – Aboard/Primary Residence(Unacceptable)
?
Multi-owner
Yes
No
?
Idle Assisted Steering
Yes
No
?
Safety Course
Yes
No
?
* = Required Field
Disclaimer Notice
- The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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