Motor Home Insurance - Quote Request

Motor Home Insurance Quote Request
Owner Name*

First NameMiddle InitialLast NameSuffix
Owner's address:*

Street Address

Street Address (con't)

CityState

Zip Code
Have you lived here over one year?*

NoYes
Prior Address:

Street Address

Street Address (con't)

CityState

Zip Code
Do you have a different mailing address or PO Box?*

No, same address as aboveYes, I have a different mailing addressOther
Mailing Address

Street Address or PO Box

Street Address Line 2

CityState

Zip Code
Home Phone Number:*
Enter Cell Phone here if that is your only phoneFormat: (000) 000-0000.
Cell Phone:
Skip, if you entered you cell phone in prior fieldFormat: (000) 000-0000.
Email address:*
Enter none@none.com if you don't have an email
Do you own your home?*

YesNo, I rentNo, I live with parentsNo, but I own and live in a Mobile HomeOther
Do you have Motor Home insurance currently, that has been in force for at least 6 months?*

YesNo I don't have insuranceNo, I never had a car before
How long have you been with your current insurance company with no lapse?

0 - 6 Months6 - 12 Months1 - 3 Years3 - 5 YearsOver 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?*
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?*

NoYes, I will sometimes rent it out to othersYes, I will use it for business purposes
Will the Motor Home be taken to a from work or used at a work location?*

NoYes
Is the Motor Home your primary residence?*

No, recreation use onlyYes
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 BrakesAnti-TheftTraction ControlNone of the above
Does the Motor Home have a trailer or tow dolly that you want covered?*

NoYes
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?*

NeitherMy car is FinancedMy 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 pleaseYes, I want full coverage with Comprehensive and Collision
List of Drivers
Driver #1*

First NameLast Name
Date of Birth - Driver #1*

MonthDayYear
Date
Gender - Driver #1*

MaleFemale
Marital Status for Driver #1:*

SingleMarriedSeparatedDivorcedWidowOther
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?*

NoYes
Date the Course was completed:

MonthDayYear
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)*

YesNo
Driver #2

First NameLast Name
Date of Birth - Driver #2

MonthDayYear
Date
Gender - Driver #2

MaleFemale
Marital Status for Driver #2:

SingleMarriedSeparatedDivorcedWidowOther
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?*

NoYes
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?

YesNo
Driver #3

First NameLast Name
Date of Birth - Driver #3

MonthDayYear
Date
Gender - Driver #3

MaleFemale
Marital Status for Driver #3:

SingleMarriedSeparatedDivorcedWidowOther
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)*

NoYes
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 meCall meIt's okay to text me on my cell phone
Any comments that you would like to add?
How did you find us?*
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?
Use this if you would like to upload a copy of your current golf cart insurance policy (optional)

Cancelof
Should be Empty:

Motor Home Insurance Quote Request

Motor Home Information

List of Drivers