RV Quote Request Form First Name Last Name Date of Birth Mailing Address Zip What type of RV do you own? ---Class A MotorhomeClass B MotorhomeClass C MotorhomeOther type of MotorhomeConventional5th WheelPop UpTruck CamperToy Hauler & Horse TrailerCargo/Utility & Horse Trailer Year Make Model Primary Use ---Pleasure UsePrimary ResidenceTaken to and From work locationsUsed at a work locationOnly vehicle in household registered for street use Primary Zip Location Was the vehicle purchased or leased? ---PurchasedLeased What year was this RV acquired Equipped with an anti theft device? ---NoneActive AlarmPassive AlarmRecovery DevicesActive/Recovery DevicesPassive/Recovery Devices Are you the original owner of the RV? YesNo Market Value of RV Gender MaleFemale Marital Status ---Single/SeparatedMarried/Civil Union/Domestic Partnership/Widowed Residency Primary Residence ---Own House/CondominiumOwn Manufactured HomeRentOther Moved in the last 2 months? ---NoYes - Moved within the U.S.Yes - Moved from outside the U.S. Driving History Driver's License Status ---ValidPermitSuspendedNot LicensedForeign Driver's License Years of RV Operating Experience Accidents, Violations, and Claims As a driver in the last 3 years, have you had any of the following regardless of fault (including automobile) Accidents, claims, or other damages you had to a vehicle? YesNo Tickets or Violations YesNo Insurance History Have you had at least 6 months of continuous RV insurance in the past 12 months? YesNo Additional Information Primary Email Address When would you need coverage?
