| Owner
Name |
* |
| E-Mail
Address |
* |
| Referred
by |
|
| Street
Address |
|
| City,
State, Zip |
,
|
| Phone |
* |
| Date |
* |
| Stated
or Agreed value? |
|
|
Insurance Company:
Name, Phone,
Fax & e-mail
|
|
| Motorcycle
Make |
|
| Motorcycle
Year |
|
| Motorcycle
Model |
|
| Motorcycle
Type |
|
| Mileage
(Verified, or Not Verified?) |
|
| License
Number |
|
| State |
|
| Country |
|
| Color |
|
| VIN |
|
| Condition |
(hold the CTRL key
to select Multiple items) |
| Frame |
|
| Front
Suspension |
|
| Rear
Suspension |
|
| Footbars |
|
| Crashbar |
|
| Paint |
|
| Flames |
|
| Trim |
|
| Fairing |
|
| Mirrors |
|
| Head
& Tail Lights |
|
| Light
Bar |
|
| Other
Lights |
|
| Engine
Operation |
|
| Engine
Condition |
|
| Electrical
Condition |
|
| Compartment
Conditions |
|
| Shock
Condition |
|
| Brakes |
|
| Tires |
|
| Wheels |
|
| Transmission |
|
| Clutch |
|
| Other
(Cust Exhaust, etc) Condition |
|
| Interior
Condition Pre-Loss |
|
| Instrument
Panel |
|
|
Intercom |
|
| Seat |
|
| Saddlebags |
|
| Radio
Operation |
|
| CB
Radio |
|
| Recent
Engine Repair Year |
|
| Recent
Engine Repair Miles |
|
| Recent
Transmission Repair Year |
|
| Recent
Transmission Repair Miles |
|
| Recent
Clutch Repair Year |
|
| Recent
Clutch Repair Miles |
|
| Recent
Tires Repair Year |
|
| Recent
Tires Repair Miles |
|
| Recent
Paint & Trim Repair Year |
|
| Recent
Paint & Trim Repair Miles |
|
| Recent
Upholstery Repair Year |
|
| Recent
Upholstery Repair Miles |
|
| Recent
Chrome Repair Year |
|
| Recent
Chrome Repair Miles |
|
| Recent
Suspension Repair Year |
|
| Recent
Suspension Repair Miles |
|
| |
|
| Overall
condition of vehicle / Any additional info you would like to add |
|
| Payment
Type |
*
MasterCard
Visa
Amex
Discover*
|
| Credit
Card number |
*
Expires:
*
|
| Card
Holder Name |
*
Billing Zip Code:
*
|
Before
submitting this form, please print a copy for your records.
In case of Internet problems, fax or mail your printed copy.
Our
Fax number is: (805) 482 6798
|