PERSONAL MOTOR HOME QUOTE 

PERSONAL INFORMATION        

        First Name                                  
        Last Name                                   
        Garaging Address                      
        Garaging City                              
        Garaging Zip Code                     
        Phone Number                            
        Fax Number                                
        E-Mail Address                           
        Who Referred You to Our Site? 
 

MAILING ADDRESS (OPTIONAL)

        Mailing Address (If Different from Garaging) 
        Mailing City                                 
        Mailing State                              
        Mailing Zip Code                        
 

DRIVER INFORMATION

Driver 1             

        First Name                
        Birthdate                    
- Male Female                                                        Sex                                          
- single married divorced widowed separated                                                    Marital Status
        Yrs Licensed  
        State Licensed
        Occupation

Violations - Minors (last 3 years) / Majors (last 7-10 years)

- None 1 2 3 4                                                             Minor Violations - Speeding, Failure to Stop, etc.

- None 1 2 3 4                                                             Accidents - Non Chargeable

- None 1 2 3 4                                                             Accidents - Chargeable

- None 1 2 3 4                                                             Major Violations - Drunk Driving, Reckless, Hit & Run, etc.

Driver 2             

        First Name                
        Birthdate                    
- Male Female                                                        Sex                                          
- single married divorced widowed separated                                                    Marital Status
        Yrs Licensed  
        State Licensed
        Occupation

        Relation to Insured

Violations - Minors (last 3 years) / Majors (last 7-10 years)

- None 1 2 3 4                                                             Minor Violations - Speeding, Failure to Stop, etc.

- None 1 2 3 4                                                             Accidents - Non Chargeable

- None 1 2 3 4                                                             Accidents - Chargeable

- None 1 2 3 4                                                             Major Violations - Drunk Driving, Reckless, Hit & Run, etc.

Driver 3             

        First Name                
        Birthdate                    
- Male Female                                                        Sex                                          
- single married divorced widowed separated                                                    Marital Status
        Yrs Licensed  
        State Licensed
        Occupation

        Relation to Insured

Violations - Minors (last 3 years) / Majors (last 7-10 years)

- None 1 2 3 4                                                             Minor Violations - Speeding, Failure to Stop, etc.

- None 1 2 3 4                                                             Accidents - Non Chargeable

- None 1 2 3 4                                                             Accidents - Chargeable

- None 1 2 3 4                                                             Major Violations - Drunk Driving, Reckless, Hit & Run, etc.

Driver 4             

        First Name                
        Birthdate                    
- Male Female                                                        Sex                                          
- single married divorced widowed separated                                                    Marital Status
        Yrs Licensed  
        State Licensed
        Occupation

        Relation to Insured

Violations - Minors (last 3 years) / Majors (last 7-10 years)

- None 1 2 3 4                                                             Minor Violations - Speeding, Failure to Stop, etc.

- None 1 2 3 4                                                             Accidents - Non Chargeable

- None 1 2 3 4                                                             Accidents - Chargeable

- None 1 2 3 4                                                             Major Violations - Drunk Driving, Reckless, Hit & Run, etc.

                       
MOTOR HOME INFORMATION

Motor Home 1    
        Year                                       
        Make                                     
        Model                                    

        Length                                  
        Serial Number  

        Purchase Price

        Purchase Date                                       
- Pleasure Business                                                       Usage                                                

- 0-3,000 3,001-5,000 5,001-8,000 8,001-10,000 10,001-12,000 12,001-15,000 15,000 +                                                 Annual Miles

Motor Home 2    
        Year                                       
        Make                                     
        Model                                    

        Length                                  
        Serial Number  

        Purchase Price

        Purchase Date                                       
- Pleasure Business                                                       Usage                                                

- 0-3,000 3,001-5,000 5,001-8,000 8,001-10,000 10,001-12,000 12,001-15,000 15,000 +                                                 Annual Miles    

                     
COVERAGE INFORMATION

- 15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000                                              Bodily Injury               
- 10,000 25,000 50,000 100,000 250,000                                                          Property Damage                        
- No Coverage 15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000                                              Uninsured Motorist

- No Coverage 3,500 Coll. Deductible Waiver                                   Uninsured Motorist Property Damage or CDW
- No Coverage 1,000 2,000 3,000 4,000 5,000                                                  Medical Payment              

DEDUCTIBLE INFORMATION

Motor Home 1     

- None 50 100 250 500 1000                                                              Comprehensive             

- None 50 100 250 500 1000                                                              Collision      

- Yes No                                                                 Towing  

- Yes No                                                                 Rental 

Motor Home 2     

- None 50 100 250 500 1000                                                              Comprehensive             

- None 50 100 250 500 1000                                                              Collision      

- Yes No                                                                 Towing  

- Yes No                                                                 Rental

ADDITIONAL COVERAGE INFORMATION

- 250 Incl. 100 500 Reasonable Expense                                      Towing                                     

- 10,000 Incl. 25,000 50,000                                                       Vacation Liability    

- 1,000 Incl. 2,000 3,000 5,000 10,000 Other                                                         Personal Property        Other:  

UNDERWRITING INFORMATION

- Yes No     Has the principal operator owned or driven a motor home for more than 12 months?

- Yes No     Does the motor home have factory/dealer built-in sleeping and/or cooking facilities?

- Yes No     Is the motor home used as a primary residence?    Full-Time    Part-Time

- Yes No     Is the motor home a converted school or public transit bus, step van, or delivery vehicle?

- Yes No     Is the motor home used in connection with any operator's business or profession?

- Yes No     Is the motor home used strictly for recreational purposes?

- Yes No     Is the motor home located in a park? 

MISCELLANEOUS INFORMATION

        Current Insurance Company   
        Expiration Date                           
        Current Premium                        

- No current insurance Less than one year 1 year 2 years 3 years 4 years 5 years or more                                      Continuously Insured               

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