Mendoza Insurance
1108 Sheridan Avenue · Chico, CA · 95926 Ph. 530-895-1086 · Fx. 530-894-6166 License #0625161
Office Hours: Mon - Fri · 9am - 5pm · (Closed Noon to 1pm)
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Current Insurance Company:
 
Please enter the following operator information for all operators:
Operator 1
Full Name
 
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Female
Single
Married
 
Current Age
 
Total Years Licensed
 
ORV Saftey Course Dates
 
Driver's License #
 
Issuing State
 
Has this operator been convicted of a moving violation or had an accident (regardless of fault or type of vehicle driven) with the past three years?
Yes No
 
If yes, provide details:
 
Operator 2
Full Name
 
Male
Female
Single
Married
 
Current Age
 
Total Years Licensed
 
ORV Saftey Course Dates
 
Driver's License #
 
Issuing State
 
Has this operator been convicted of a moving violation or had an accident (regardless of fault or type of vehicle driven) with the past three years?
Yes No
 
If yes, provide details:
 
Operator 3
Full Name
 
Male
Female
Single
Married
 
Current Age
 
Total Years Licensed
 
ORV Saftey Course Dates
 
Driver's License #
 
Issuing State
 
Has this operator been convicted of a moving violation or had an accident (regardless of fault or type of vehicle driven) with the past three years?
Yes No
 
If yes, provide details:
 
 
Please enter the following vehicle information for all off-road vehicles:
Are all vehicles with physical damage coverage garaged or stored
in a fully enclosed, locked structure when not in use? Yes No
Vehicle 1
Vehicle Class
 
Make
 
Model
 
Model Year
 
CC Size
 
Current Market Value
$
 
Use
 
Estimated Annual Mileage
 
Vehicle Identification Number
(Helps Determine Discounts)
 
Number Of Wheels
 
Garaging Location
(If different from mailing address)
Address
 
City
 
State & ZIP
 
Coverage
Bodily Injury Liability
(Includes Passenger Liability)
 
Property Damage Liability
 
Bodily Injury/
Property Damage
Combined Single Limit
(Includes Passenger Liability)
 
Medical Payments
 
Collision Deductible Options
$
 
Other Than
Collision Deductible Options
$
 
Optional Equipment
(Indicate how much
coverage is needed)
$
 
Vehicle 2
Vehicle Class
 
Make
 
Model
 
Model Year
 
CC Size
 
Current Market Value
$
 
Use
 
Estimated Annual Mileage
 
Vehicle Identification Number
(Helps Determine Discounts)
 
Number Of Wheels
 
Garaging Location
(If different from mailing address)
Address
 
City
 
State & ZIP
 
Coverage
Bodily Injury Liability
(Includes Passenger Liability)
 
Property Damage Liability
 
Bodily Injury/
Property Damage
Combined Single Limit
(Includes Passenger Liability)
 
Medical Payments
 
Collision Deductible Options
$
 
Other Than
Collision Deductible Options
$
 
Optional Equipment
(Indicate how much
coverage is needed)
$
 
Vehicle 3
Vehicle Class
 
Make
 
Model
 
Model Year
 
CC Size
 
Current Market Value
$
 
Use
 
Estimated Annual Mileage
 
Vehicle Identification Number
(Helps Determine Discounts)
 
Number Of Wheels
 
Garaging Location
(If different from mailing address)
Address
 
City
 
State & ZIP
 
Coverage
Bodily Injury Liability
(Includes Passenger Liability)
 
Property Damage Liability
 
Bodily Injury/
Property Damage
Combined Single Limit
(Includes Passenger Liability)
 
Medical Payments
 
Collision Deductible Options
$
 
Other Than
Collision Deductible Options
$
 
Optional Equipment
(Indicate how much
coverage is needed)
$
 
Transport Trailer
Make
Model
Model Year
Value $
Serial Number
 
Indicate amount of coverage needed: $
 
Additional Comments Or Questions