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		Motorcycle Policyholder Name: First M.I. Last Current Insurance Provider: Do you have a current policy with UIP Insurance Partners?: Yes: No: If Yes, please provide Policy Number and Insurance Provider Policy Number: Insurance Provider: Expiration Date: / / mm/dd/yy Contact Phone No.: E-mail address:     Class M License?: Choose Yes No If Yes, enter year issued: yyyy Vehicle Information Is this vehicle Homemade, Kit, or does it have a State Assigned VIN: Yes: No: If Yes enter year: yyyy Vehicle Make: Model: CC Size: Is Motorcycle a Trike?: Yes: No: Garaging Zip Code: Annual Miles:       Get the United Advantage Insurance products are available through United Agencies and it's affiliates including UIP Insurance Services, LLC. California Insurance License No.0252636. 2 0 1 0   U I P   I n s u r a n c e   S e r v i c e s ,   L L C.  •  L i c e n s e   N o.  0 2 5 2 6 3 6  •   P r i v a c y   P o l i c y