Motor Home and Travel Trailer Quote Form


GENERAL INFORMATION
Named Insured:
Mailing Address:
City:
State:	Illinois
Zip/Postal:
Social Security #:
Drivers License #:
Date of Birth:
E-Mail
Phone:
Fax

MOTOR HOME INFORMATION (SCROLL DOWN FOR TRAVEL TRAILER INFORMATION)
Year:
Make:
Model:
How Many Years of Motor Home Driving Experience?:
Any Tickets or Accidents Last 36 Months? (Please list all tickets and accidents in box below)	Yes No
Do You Want Physical Coverage?	Yes No
Current Value of Unit:

COVERAGES
Liability:	$20/40 BI / 15 PD $25/50 BI / 25 PD $50/100 BI / 25 PD $100/300 BI / 50 PD $100/300 BI / 100 PD $250/500 BI / 100 PD
Medical:	$500 $1000 $2000 $5000
Tow Coverage:	Yes No
Deductible on Unit:	$100 $250 $500 $1000 $1500 $2000 $2500

TRAVEL TRAILER INFORMATION
Type of Unit:	Travel Trailer Pop Up Fifth Wheel Truck Mounted
Year:
Make:		Model:
Width:		Length:

COVERAGES
Current Value of Unit:
Is Unit Stationary (Parked and Not Moved)?:	Yes No
Deductible:	$100 $250 $500 $750
Pay Plan:	1 2 4 6 Payments

NOTICE: Some companies use an insurance score. This can often improve your rate. If you would like us to use this underwriting tool please provide us your social security number above in the dedicated box or in the remarks box below.

(Rules of the Fair Reporting Credit Act and Federal Consumer Credit Protection Law, will apply)

ADDITIONAL INFORMATION
Please use this section to explain any violations, accidents or claims/losses.