Modified Stock & Custom Cycle Insurance Application & Appraisal Form

Thank you for inquiring with us for your motorcycle insurance needs. You’ve indicated that you are interested in a quote for insurance on your custom cycle. Before we can provide a quote, our underwriting guidelines and procedures require a completed submission/appraisal form and other supplementary materials. The instructions provided below will help avoid any delays in processing of your submission.

Receipt and/or completion of this submission does NOT guarantee or bind coverage and is NOT proof of insurance.

Please review this form carefully, type your information and press the submit button -or- if you prefer to print this form and fill it in by hand, just print it now (or bookmark it to come back later). The address or fax number for hand written applications is:

BrosClub~CycleServices Insurance Program
PO Box 3238, South Pasadena, CA 91031-6238 Fax: 626-683-7682

This application has 4 sections:

SECTION A - Cycle ownership and general information - to be completed by all applicants
SECTION B - Modified or highly customized valuation - stock cycle applicants only
SECTION C - Fully custom made valuation - custom made cycle applicants only
SECTION D - Signature and Authenticity Declaration - to be completed by all applicants

IMPORTANT: For fully custom made cycle applications, in addition to completing section A and D, please be sure that the component valuations in SECTION C are carefully completed. If our quote is acceptable to you, you'll need to have an authorized shop sign off on it in order to finalize coverage.

Once your quotation has been formalized, and if you elect to proceed to obtain a policy, the following items will be required in order to activate coverage:

Yes No	All pages of the application form, including this page
Yes No	Five legible, COLOR photographs of unit: FRONT, BACK, LEFT, RIGHT, MOTOR
Yes No	Copy of your current declarations page if you have insurance for the unit

Any photographs or appraisal materials sent to our office will NOT be returned.

Our Custom Team will review the submission and materials within 3-4 business days of receipt. You will then receive mail confirmation of denial or approval for this unit. If the unit has been approved, we will contact you to complete your quote or to arrange coverage. Submission must be approved before a quote can be completed and before insurance coverage can be purchased.

SECTION A - Cycle Ownership & General Information

Owner information:

First Name: (REQUIRED)
Initial: Last Name: (REQUIRED)

Street Address: (REQUIRED)

City: (REQUIRED)
State: (REQUIRED) Coverage NOT AVAILABLE for North Carolina, Massachusetts, New Jersey & Hawaii
Zip: (REQUIRED)

Phone: (REQUIRED)
Email: (PLEASE DOUBLE CHECK)

Tickets or 'At Fault' Accidents
(Last 4 Years) (REQUIRED)
Yes No Date of Birth: (REQUIRED)
Driver's Lic#: (REQUIRED)

Motorcycle Information: (put CUSTOM if not applicable)

Year: (REQUIRED)
Make: (REQUIRED)
Model: (REQUIRED)

Degree of Rake**: (REQUIRED)
Engine Size: (REQUIRED)
VIN (Vehicle ID Number): (REQUIRED)

**Total degree of rake includes any extensions/stretching on the gas tank, triple trees and/or forks (required to determine best carrier).

Does Your Cycle Have The Following: (A RESPONSE TO THESE QUESTIONS IS REQUIRED)

Front and rear fenders? Yes
No Brake light? Yes
No Front and rear turn signals? Yes
No

Total degree of rake** less than 40 degrees? Yes
No Standard handlebar style?

SECTION B - Stock Cycle Modification/Accessory/Customization Valuation:

Individually list all non-stock accessories and any customization below. A dollar value must also be included per line. The amount listed should NOT include labor cost. Internal engine, transmission and maintenance parts should not be included. (For custom built units, please skip to section B)

1. 2.

3. 4.

5. 6.

7. 8.

9. 10.

11. 12.

13. 14.

15. 16.

Accessory Total: (REQUIRED)
$

SECTION C - Custom Cycle Appraisal & Shop Verification

To assist in determining the current market value, this page must be verified by an Authorized Shop after policy approval has been granted:

Frame / Suspension	Brand	Price	Comments
Frame
Swingarm
Forks/Triple Clamps
Shocks
Final Drive
H Bars/Controls
Wheels / Brakes	Brand	Price	Comments
Wheels – Front/Rear
Tires
Master Cylinder – F/R
Calipers – Front/Rear
Rotors – Front/Rear
Engine / Transmission	Brand	Price	Comments
Engine
Transmission
Oil Tank/Cooler/Lines
Electronics (Ignition, etc)
Carburetion/Injection
Primary Drive
Body Work	Brand	Price	Comments
Fuel Tank
Fenders
Paint

Authorized Shop Name:	Address:
Phone:	Email:

Consider the current market value of the cycle (including optional equipment). The market value should be based on similar cycles that are for sale presently and/or the value for which similar models have recently sold. This does not include labor costs. Insured value of unit is subject to underwriting approval.

Estimated Market Value:(REQ'D) $ Appraiser’s Signature: ________________________

Appraiser (Print Name): _______________________________ Date: _____________________

SECTION D - Motorcycle Insurance Applicant Authenticity Declaration and Signature

Fraud Warning: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. In Pennsylvania, any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.

As part of the company's underwriting procedure, a routine inquiry may be made which will provide applicable information concerning your driving record. Upon written request, a copy of this report will be provided to you under the Federal Fair Credit Reporting Act (Public Law (91-508)).

I understand that approval of this submission is subject to compliance with Company’s underwriting guidelines and procedures and that submission does not guarantee or bind coverage and is not proof of insurance. By typing or signing my name below, I attest that my statements within this appraisal form are true and valid to the best of my knowledge and belief.

Applicant Signature: (REQUIRED)

Date: (REQUIRED)

(For electronic applications, typing your name above constitutes a legal signature)

Submission does NOT guarantee or bind coverage and is NOT proof of insurance.

Additional Applicant Comments:

Please press the SEND button above to transmit your application, then print the page (if desired). You should receive an email confirmation automatically; if there are any problems, please contact us online at:

http://Brosclub.org/Contact.html
or phone at 800-547-2767 (option 2)

Owner information:
First Name: (REQUIRED)	Initial: Last Name: (REQUIRED)
Street Address: (REQUIRED)
City: (REQUIRED)	State: (REQUIRED) Coverage NOT AVAILABLE for North Carolina, Massachusetts, New Jersey & Hawaii	Zip: (REQUIRED)
Phone: (REQUIRED)	Email: (PLEASE DOUBLE CHECK)