RV/Motorhome Quote

*Fields marked in red are required*

Personal Information:

First Name		Last Name
Street Address
City		State
Zip
Primary Phone
Secondary Phone
Social Security #
E-mail
Do you currently have Motor Home Insurance	--Please Select-- Yes No
	If yes, how long have you had continuous coverage?	Years	Months
	Present insurance company
	Policy Number:
	When does your policy expire?		ex: 09/30/2005
If no, why?	--Please Select-- Cancelled Non-Renewed Other
	If Other, why?

Driver Information:

Driver 1		Driver 2
First Name		First Name
Last Name		Last Name
Date of Birth		Date of Birth
Sex	Male Female	Sex	Male Female
Date Licensed		Date Licensed
License Number		License Number
License State		License State

Driver 3		Driver 4
First Name		First Name
Last Name		Last Name
Date of Birth		Date of Birth
Sex	Male Female	Sex	Male Female
Date Licensed		Date Licensed
License Number		License Number
License State		License State

Vehicle Information:

Vehicle 1		Vehicle 2
Year		Year
Make		Make
Model		Model
Odometer		Odometer
VIN		VIN
Annual Mileage		Annual Mileage
Anti-Theft Device	--Please Select-- Yes No	Anti-Theft Device	--Please Select-- Yes No

Vehicle 3		Vehicle 4
Year		Year
Make		Make
Model		Model
Odometer		Odometer
VIN		VIN
Annual Mileage		Annual Mileage
Anti-Theft Device	--Please Select-- Yes No	Anti-Theft Device	--Please Select-- Yes No

 

Do any drivers have any accidents/violations in the last 5 years?	--Please Select-- Yes No
Please list the Driver # Accident/Violation Type Date Description of Incident If Accident	--Please Select-- Not at Fault At Fault
Have you owned a motor home for more than 12 months?	--Please Select-- Yes No
Does the motor home have Factor/Dealer built-in sleeping and cooking facilities?	--Please Select-- Yes No
Will the motor home be your primary residence?	--Please Select-- Yes No
Is the vehicle a converted school or public transportation bus, step van, or delivery vehicle?	--Please Select-- Yes No
Is the motor home used in connection with any operators business or profession?	--Please Select-- Yes No
Is the motor home used strictly for recreational purposes?	--Please Select-- Yes No

Coverage Limits:

Bodily Injury Coverage	- 100,000/300,000
Property Damage Coverage	- 50
Comprehensive Deductible	--Please Select-- None 500 1000 2000
Collision Deductible	--Please Select-- None 500 1000 2000

Other Coverages:

Emergency Expense - ($500 Per Loss)	--Please Select-- Yes No
Towing and Roadside Assistance	--Please Select-- None 100 250 500
Personal Property - Actual Cash Value
Replacement Cost Personal Property Limit