Current RV/Travel Trailer Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Term:	6 Months   1 Year   Other:

Vehicle Information
Vehicle #1	Vehicle to be covered is a:		Recreational Vehicle (RV)     Travel Trailer
	Year	Make	Model	Type
				Select Vehicle to be covered above
Multi-Owner		Rating Base (Current Value)	Annual Milage	Vehicle Use
Y N				Occupied <30 Days/Yr Pleasure Occupied 30-150 Days/Yr Pleasure Occupied >150 Days/Yr Pleasure Traveling Primary Residence Non-Traveling Primary Residence
AntiTheft		Full-Timers Liability Options*	Roadside Assistance/ Towing	Physical Damage Option
Y N		Y N	Y N	Actual Cash Value Agreed Value Replace Cost - New Purchase Only
Collision		Comprehensive	Emergency Expenses**	Vacation Liability***
Y N		Y N	Y N	Y N
Please complete the section below for RV (Recreational Vehicle) coverage ONLY!
(PIP) Personal Injury Protection Coverage****		(BIPD)Bodily Injury and Property Damage Coverage		(UM) Uninsure Motorist / (UIM) Underinsured Motorist
Y N		Y N		Y N
Does Primary Insured have Medical/Disability Coverage?		*  Available when Vehicle is Used as a Primary Residence   **  Covers Temporary Living Expense Cost to Move RV/Travel Trailer   ***  Covers BI/PD Liability when Vehicle is used as a residence on Vacation  ****  If Primary Insured already has medical/disability coverage, they may be eligible for a discount on PIP Coverage
Y N

Vehicle #2	Vehicle to be covered is a:		Recreational Vehicle (RV)     Travel Trailer
	Year	Make	Model	Type
				Select Vehicle to be covered above
Multi-Owner		Rating Base (Current Value)	Annual Milage	Vehicle Use
Y N				Occupied <30 Days/Yr Pleasure Occupied 30-150 Days/Yr Pleasure Occupied >150 Days/Yr Pleasure Traveling Primary Residence Non-Traveling Primary Residence
AntiTheft		Full-Timers Liability Options*	Roadside Assistance/ Towing	Physical Damage Option
Y N		Y N	Y N	Actual Cash Value Agreed Value Replace Cost - New Purchase Only
Collision		Comprehensive	Emergency Expenses**	Vacation Liability***
Y N		Y N	Y N	Y N
Please complete the section below for RV (Recreational Vehicle) coverage ONLY!
(PIP) Personal Injury Protection Coverage****		(BIPD)Bodily Injury and Property Damage Coverage		(UM) Uninsure Motorist / (UIM) Underinsured Motorist
Y N		Y N		Y N
Does Primary Insured have Medical/Disability Coverage?		*  Available when Vehicle is Used as a Primary Residence   **  Covers Temporary Living Expense Cost to Move RV/Travel Trailer   ***  Covers BI/PD Liability when Vehicle is used as a residence on Vacation  ****  If Primary Insured already has medical/disability coverage, they may be eligible for a discount on PIP Coverage
Y N

Driver Information
(include all licensed drivers in your household)
Driver #1	Driver's Name		Drivers License Information
			DL#:   State:   Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Soc. Sec. #	Courses Completed Last 3 yrs
		M  F	M  S		Drivers Ed: Y N Accident Prevention: Y N

Driver #2	Driver's Name		Drivers License Information
			DL#:   State:   Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Soc. Sec. #	Courses Completed Last 3 yrs
		M  F	M  S		Drivers Ed: Y N Accident Prevention: Y N

Driver History
Please list ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years
Driver	Date	Type of Conviction	Fines	Speed Over Limit
			$	mph
			$	mph

Please list ANY driver who has had license suspensions, revocations or DUI convictions below
Driver	License Suspended or Revoked	DUI Conviction For:
	Suspended   Revoked	Alcohol   Drugs
	Suspended   Revoked	Alcohol   Drugs

Please list ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver	Date	Description	Cost	Fines	Injuries	At Fault
			$	$	Yes	Yes
			$	$	Yes	Yes

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.

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