Contact and Garaging Information
*First Name
*Last Name
*Garaging Street Address
City/St/Zip
Phone Number
Alternate Number
*Email Address
Mailing Address - if different from above
Mailing Address
Driver 1 Information
First Name
Last Name
Gender
Male Female
Birthdate
Drivers License Number
Marital Status
-Select- Single Married Separated Divorced Widowed Domestic Partner
Years Licensed
State Licensed
Occupation
Driver 2 Information
First Name
Last Name
Gender
Male Female
Birthdate
Drivers License Number
Marital Status
-Select- Single Married Separated Divorced Widowed Domestic Partner
Years Licensed
State Licensed
Occupation
Motorhome Information
Year
Make
Model
Vin #
Cost New Value
Vehicle Type
-Select- Conventional (Class A) Mini Motorhome (Class C) Camper Van (Class B Bus Conversion Other
Miles per Year
Ownership
-Select- Leased Paid Off Financed
Violation Information -
Last 3 years (minor violations) / Last 5 years (major violations)
Driver 1
Minor Violations - speeding, turn, stop sign, red light, etc.
-Select- None 1 2 3 4
Accidents - non chargeable
-Select- None 1 2 3 4
Accidents - chargeable
-Select- None 1 2 3 4
Major violations - drunk driving, reckless,hit and run, etc.
-Select- None 1 2 3 4
Driver 2
Minor Violations - speeding, turn, stop sign, red light, etc.
-Select- None 1 2 3 4
Accidents - non chargeable
-Select- None 1 2 3 4
Accidents - chargeable
-Select- None 1 2 3 4
Major violations - drunk driving, reckless,hit and run, etc.
-Select- None 1 2 3 4
Miscellaneous Information
Is the Motorhome used as a primary residence?
Yes No
Is the Motorhome the only vehicle in the household?
Yes No
Do you currently own a home?
Yes No
Do you currently have a Motorhome policy?
Yes No
Is or will the Motorhome be rented or leased?
Yes No
Is or will the Motorhome be used strictly for recreational purposes?
Yes No
Is or will the Motorhome be used in connection with any operator's business or profession?
Yes No
Is the Motorhome a converted school or public transit bus?
Yes No
Is the Motorhome owned by two or more individuals residing in separate households?
Yes No
What is the estimated annual mileage?
In which state is or will the Motorhome be registered in?
Current Insurance Company
Expiration Date
Current Premium
Coverage Information
Personal Liability / Bodily Injury
-Select- 15,000/30,000 25,000/50,000 30,000/60,000 50,000/100,000 100,000/300,000 250,000/500,000
Personal Liability / Property Damage
-Select- 5,000 10,000 25,000 50,000 100,000
Uninsured Motorist / Bodily Injury
-Select- No Coverage 15,000/30,000 25,000/50,000 30,000/60,000 50,000/100,000 100,000/300,000 250,000/500,000
Uninsured Motorist / Property Damage
-Select- No Coverage 3,500 Deductible Waiver
Medical Payment
-Select- No Coverage 1,000 1,500 2,000 2,500 5,000 10,000 15,000 20,000 25,000 50,000 100,000
Deductible Information
Comp (theft)
-Select- None 250 500 1,500 2,000
Collision
-Select- None 250 500 1,500 2,000
Questions or Comments
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