Motor Home Insurance Quote Request
Owner Name
*
First Name
Middle Initial
Last Name
Suffix
Owner's address:
*
Street Address
Street Address (con't)
City
State
Zip Code
Have you lived here over one year?
*
No
Yes
Prior Address:
Street Address
Street Address (con't)
City
State
Zip Code
Do you have a different mailing address or PO Box?
*
No, same address as above
Yes, I have a different mailing address
Other
Mailing Address
Street Address or PO Box
Street Address Line 2
City
State
Zip Code
Home Phone Number:
*
Enter Cell Phone here if that is your only phone
Cell Phone:
Skip, if you entered you cell phone in prior field
Email address:
*
Enter none@none.com if you don't have an email
Do you own your home?
*
Yes
No, I rent
No, I live with parents
No, but I own and live in a Mobile Home
Other
Do you have Motor Home insurance currently, that has been in force for at least 6 months?
*
Yes
No I don't have insurance
No, I never had a car before
How long have you been with your current insurance company with no lapse?
0 - 6 Months
6 - 12 Months
1 - 3 Years
3 - 5 Years
Over 5 Years
What is the name of your current insurance company?
When will (or did) your policy expire?
Motor Home Information
What is the Year, Make, Model?
*
Ex: 2018 Coachmen Freelander
VIN number (you can skip, but this is needed in many cases)
Optional for a quote, but will be required to issue a policy
Length of Motor Home:
*
How many Slides?
*
Please Select
0
1
2
3
4
Value of the Motor Home:
*
Enter the value plus all permanently attached equipment
What year did you purchase this Motor Home?
*
In what zip code will the Motor Home usually be stored?
*
Will the Motor Home be rented to others or used in Business?
*
No
Yes, I will sometimes rent it out to others
Yes, I will use it for business purposes
Will the Motor Home be taken to a from work or used at a work location?
*
No
Yes
Is the Motor Home your primary residence?
*
No, recreation use only
Yes
Best guess on the number of days per year the Motor Home is used?
*
Do you own an automobile for everyday driving?
*
Does the Motor Home have any of the following options: (check all that apply)
Anti-lock Brakes
Anti-Theft
Traction Control
None of the above
Does the Motor Home have a trailer or tow dolly that you want covered?
*
No
Yes
Please give details of the trailer or tow dolly, including the Value:
Who is the primary driver of Cart #1?
*
Is Cart #1 either Financed or Leased?
*
Neither
My car is Financed
My car is Leased
Optional: Name of your lienholder or lessor (address if available)
This is not required to get a quote from us.
Do you want FULL COVERAGE on the Motor Home?
*
No, Liability only please
Yes, I want full coverage with Comprehensive and Collision
List of Drivers
Driver #1
*
First Name
Last Name
Date of Birth - Driver #1
*
-
Month
-
Day
Year
Date
Gender - Driver #1
*
Male
Female
Marital Status for Driver #1:
*
Single
Married
Separated
Divorced
Widow
Other
Drivers License Number and State for Driver #1:
Ex: A12345678912345 - NJ
How many years of experience has this driver had operating a Motor Home or RV:
*
Has driver#1 taken a defensive driving course?
*
No
Yes
Date the Course was completed:
-
Month
-
Day
Year
Date
Describe any Moving Violations or Accidents within 3 years for Driver #1:
*
If no tickets or accidents within 5 years, please type NONE
Add another Driver? (If you are married, spouse info is needed)
*
Yes
No
Driver #2
First Name
Last Name
Date of Birth - Driver #2
-
Month
-
Day
Year
Date
Gender - Driver #2
Male
Female
Marital Status for Driver #2:
Single
Married
Separated
Divorced
Widow
Other
Drivers License Number and State for Driver #2 (if never licensed, indicate NEVER LICENSED):
Ex: A12345678912345 - NJ
How many years of experience has driver #2 had operating any type of Motor Home or RV)?
*
Has driver#2 taken a Defensive Driving course?
*
No
Yes
Describe any Moving Violations or Accidents within 5 years for Driver #2:
If no tickets or accidents within 5 years, please type NONE
Add a 3rd Driver?
Yes
No
Driver #3
First Name
Last Name
Date of Birth - Driver #3
-
Month
-
Day
Year
Date
Gender - Driver #3
Male
Female
Marital Status for Driver #3:
Single
Married
Separated
Divorced
Widow
Other
Drivers License Number and State for Driver #3:
Ex: A12345678912345 - NJ
How many years of experience has driver #3 had operating any type of off-road vehicle (such as a golf cart)?
*
Has driver#3 taken a Defensive Driving course? (within the past two years)
*
No
Yes
Describe any Moving Violations or Accidents within 5 years for Driver #3:
If no tickets or accidents within 5 years, please type NONE
How would you like us to contact you? (check as many as you want)
*
Email me
Call me
It's okay to text me on my cell phone
Any comments that you would like to add?
How did you find us?
*
Please Select
Existing Customer
Google search
Referred by friend
Referred by realtor
Other
Were you referred to us by someone? If so, please let us know who referred you so we can send them a thank you.
Would you like this quote request sent to a specific person in our office?
Please Select
Ares
Carol
Debbie
George
Jason
Tammy
No, new customer
Use this if you would like to upload a copy of your current golf cart insurance policy (optional)
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