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RV_Quote
Fields marked with
*
are required.
RV OWNER INFORMATION
*
First Name:
Middle Initial:
*
Last Name (or Company Name):
*
Telephone (Day):
Telephone (Evening):
Fax:
*
Address:
*
City:
State:
*
Zip Code:
*
Dwelling:
Homeowner
Rent
Live with parent(s)
Other
*
Date of Birth:
*
Marital Status:
Married/Widowed
Single/Divorced/Separated
*
Email Address:
Years of RV Ownership:
*
Claims/Accidents in last 5 years:
No
Yes
If yes, please explain including dates and amounts paid:
Current Insurance Company:
Current Premium:
VEHICLE DETAILS
*
Year:
*
RV Type:
Conventional - Class A
Mini Motor Home - Class C
Camper Van - Class B
Professional Bus Conversion
Non-Professional Bus Conversion
Travel Trailer / Fifth Wheel
Pop-Up Camper
*
RV Make:
*
RV Model:
*
RV Value (Rating Base):
*
Garaging Zip Code:
*
Vehicle Use:
Rec Use < 30 days per year
Rec Use - 30 - 150 days per year
Rec Use > 150 days per year
Primary Residence - Multiple Locations Per Year
Primary Residence - One Location
Business/Commercial - Unacceptable
Only Vehicle in Household - Unacceptable
Rented or Leased to Others - Unacceptable
COVERAGE OPTIONS
*
Physical Damage Coverage:
Total Loss Replacement
Agreed Value
Actual Cash Value (ACV)
Liability Only
*
Comprehensive Deductible:
$250
$500
$1,000
$2,500
*
Collision Deductible:
$250
$500
$1,000
$2,500
*
Liability:
$50,000
$100,000
$300,000
$500,000
*
Uninsured/Underinsured Motorist Liability Coverage:
Yes
No
*
Medical Payments:
$1,000
$2,500
$5,000
$10,000
*
Emergency Expense:
$750
$2,000
*
Vacation Liability:
$10,000
$25,000
$50,000
$100,000
$250,000
$300,000
$500,000
*
Personal Effects ($0-$99,000):
Lienholder Information (including address):
Notes To Underwriter:
*
How Did You Hear About Us? :
DEALERSHIP INFORMATION (if applicable)
Dealer Name:
Dealer Address:
Dealer Contact:
Dealer City, State, Zip:
Dealer Phone Number: