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Request for Approval on Custom Assembled or State Assigned VIN Motorcycle
Please fill out the form below to request approval on a custom assembled or state assigned VIN motorcycle. When you have finished filling out the form, click the “SUBMIT” button at the bottom of the page. Custom motorcycles are settled on a actual cash value basis.

For questions regarding this request form, please contact Joanne Malucky at 800-759-9008 ext. 6170 or
Fields marked with * are required for submission.
Agency Information
Agency Name:   * Agency Code:   *
Agency Telephone:  ( ) -  * Agency E-mail: 
Applicant Information
Name:   *
Street Address:   *
City:   * State:   *
Zip Code:   *
Motorcycle Information
Brand Name:   * Model Year:   (yyyy) *
Purchase Date:   * (mm/dd/yyyy)
Purchase Price:  $  * Motorcycle Value:  $  *
Frame ID Number   * State Assigned VIN: 
Engine Year:   * Engine CC's:   *
Engine Make:   * Engine ID Number:   *
Transmission Year:   * Transmission Model:   *
Transmission ID Number:   * Prior Insurance Carrier: 
Prior Ins. Expiration Date: 
Type of Coverage Desired:  Liability Only      Full Coverage * Form Completed By:   *
Was motorcycle state inspected?  Yes      No If Yes, which state inspected? 
Motorcycle Builder Information
Name: 
Street Address: 
City:  State: 
Zip Code: 
Previous Owner Information (if applicable)
Name: 
Street Address: 
City:  State: 
Zip Code: 
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Last Updated on November 8, 2006