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Utah insurance quotes from the the Sergakis Agency

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Sergakis Insurance Agency
8300 S. 700 E., Suite 200
Sandy, UT 84070
Phone: 801-432-2100
Toll Free: 800-928-8175
Fax: 801-432-2101

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On-Line Motorcycle Insurance Quote Form One Simple Form - takes only 2-3 Minutes! YOUR PERSONAL DATA:
Your Name:
Street Address:
City:
State: (Must be Utah)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):

Marital Status: Single Married	Homeowner? Yes No

Currently Insured? (If yes, list carrier, and # of years continuous. If no, type NONE)


DRIVER INFORMATION #1
Name:		Birthdate:
:		# Years U.S. Auto License:
Cycle Safety Course?		# Years U.S. Cycle License:
Number & Type of Accidents within last 3 years:		Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations within last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	Comments or Remarks?

DRIVER INFORMATION #2 (if none, leave blank)
Name:		Birthdate:
:		# Years U.S. Auto License:
Cycle Safety Course?		# Years U.S. Cycle License:
Number & Type of Accidents within last 3 years:		Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations within last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	Comments or Remarks?

VEHICLE #1 INFORMATION
Year of vehicle:		Make & :
Is this a 4 Wheeler?:		If Yes, Describe:
Annual Mileage:		# of CC's:
Value of Bike:	$	Special Equipment Value:	$
VEHICLE #1 COVERAGES:
Limits of Liability:	$25/65 BI / 15 PD $25/65 BI / 25 PD $50/100 BI / 50 PD $100/300 BI / 50 PD

Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Do you want Medical Coverage?	Yes No	Uninsured Motorists Cov.?	Yes No

VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:		Make & :
Is this a 4 Wheeler?:		If Yes, Describe:
Annual Mileage:		# of CC's:
Value of Bike:	$	Special Equipment Value:	$
VEHICLE #2 COVERAGES:
Limits of Liability:	$25/65 BI / 15 PD $25/65 BI / 25 PD $50/100 BI / 50 PD $100/300 BI / 50 PD

Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Do you want Medical Coverage?	Yes No	Uninsured Motorists Cov.?	Yes No

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