"I have had my personal and commercial Insurance with Leech & Hicks, Inc. for over twenty years, the prices and service are top notch."
- Tom Dewitt, Dewitt Real Estate & Auctions

Motorcycle Insurance Form

Complete the following:
* Required Fields

First Name:	*
Last Name:	*
Address:	*
City:	*
State:	*
Zipcode:	*
Phone:	*
Number of Vehicles:	*
Number of Drivers:	*
Name of Driver:	*
Date of Birth:	*
Marital Status:	*
Driving Record for Last 3 Years, include date if known:
Name of Driver #2:
Date of Birth:
Marital Status:
Driving Record for Last 3 Years, include date if known:

Vehicle #1

Year:
Make:
Model:

Vehicle #2

Year:
Make:
Model:

Discount Questions

Do you own your own Home?	Yes  No
Have you had Previous Insurance for 6 Months with no lapse in coverage?	Yes  No
If so what company:
Would you like to pay in full?	Yes  No
How is your Financial Credit?
How did you hear about Leech & Hicks?
What agency and/or agent?