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    Personal Information

  • 2

    Vehicle Information

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    Coverage & Submit

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Personal Information

First Name*
Last Name*
Personal Email*
Phone Number*
Are you affiliated with US/NATO Forces?* YesNo
Where will the vehicle be registered?* USAREURGerman registry
Are you married?* YesNo
Date of Birth*

Are you currently insured with GEICO?YesNo
GEICO policy number
Motorcycle make*
Motorcycle model*
Year of vehicle*
VIN - Vehicle Identification Number
Horse Power
Actual Cash Value in USD* (max. value 20,000 USD)
2nd Driver Information
2nd Driver First Name
2nd Driver Last Name
Is there a lien on your vehicle?* YesNo
Have you had any at-fault accidents in the last five years?* YesNo

Third Party Liability Insurance incl. Motor Assistance Coverage (mandatory)*
Comprehensive Coverage (e.g. theft, broken windshield, natural hazard) Deductible 300 EUR*
YesNo
Collision Coverage (own damage) Deductible 300 EUR (Note: If you select to have Collision Coverage, you will also carry Comprehensive Coverage with a 300 EUR deductible)*
YesNo
Effective date of coverage*
PCS Date / DEROS
I hereby consent to my data submitted in the contact form being collected and processed in order to answer my request.