Insured Information
What is your first name? *
What is your last name? *
What is your email address? *
What is your phone number? *
What is your occupation? *
What is your employer name? *
What is your date of birth? *
MM slash DD slash YYYY
What is your driver's license number? *
What state are you licensed in? *
What is your social security number? (Optional, but may
help in states where good credit
provides more favorable rates)
What is your gender?
How many years experience do you have operating RVs/Motorhomes?
Have you had any moving violations in the past five years?
Please enter the requested details for each moving violation below.
What is your marital status?
What is your spouse’s full name?
What is your spouse's date of birth?
MM slash DD slash YYYY
What is your spouse's driver's license number?
What state is your spouse licensed in?
What is your spouse’s social security number?
What is your spouse's gender?
How many years experience does your spouse have operating RVs/Motorhomes?
Has your spouse had any moving violations in the past five years?
Please enter the requested details for each of your spouse’s moving violations below.
What is your fiancé’s full name?
What is your fiancé’s date of birth?
MM slash DD slash YYYY
What is your fiancé’s driver's license number?
What state is your fiancé licensed in?
What is your fiancé’s social security number?
What is your fiancé’s gender?
How many years experience does your fiancé have operating RVs/Motorhomes?
Has your fiancé had any moving violations in the past five years?
Please enter the requested details for each of your fiancé’s moving violations below.
What is your mailing address? *
Is the mailing address the same as the principle garaging/storage location?
What is the principle garaging/storage location address?
Is the registration address different from the mailing/garaging/storage address?
What is the registration
address?
What county is the unit garaged or located in?
Additional Drivers
Are there any additional drivers that need to be listed? *
First Additional Driver
What is the first additional driver’s full name?
What is the first additional driver’s date of birth?
MM slash DD slash YYYY
What is the first additional driver’s license number?
What state is the first additional driver licensed in?
What is the first additional driver’s social security number?
What is the first additional driver’s gender?
How many years experience does the first additional driver have operating RVs/Motorhomes?
Has the first additional driver had any moving violations in the past five years?
Please enter the requested details for each of your fiancé’s moving violations below.
Has the first additional driver had any claims in the past five years?
Please enter the requested details for each of the first additional driver’s claims below.
Is there a second additional driver that needs to be listed?
Second Additional Driver
What is the second additional driver’s full name?
What is the second additional driver’s date of birth?
MM slash DD slash YYYY
What is the second additional driver’s license number?
What state is the second additional driver licensed in?
What is the second additional driver’s social security number?
What is the second additional driver’s gender?
How many years experience does the second additional driver have operating RVs/Motorhomes?
Has the second additional driver had any moving violations in the past five years?
Please enter the requested details for each of the second additional driver’s moving violations below.
Has the second additional driver had any claims in the past five years?
Please enter the requested details for each of the second additional driver’s claims below.
Vehicle Information
Are you in the process of purchasing this vehicle? *
What is the purchase price?
What date do you take delivery of the vehicle? *
MM slash DD slash YYYY
What is the current value of this vehicle?
What date would you like this policy to go into effect? *
MM slash DD slash YYYY
Do you currently have insurance in place for this vehicle?
What is the name of your insurance company?
Please upload a copy of your current policy, if convenient.
What is the year, make and model of this vehicle? *
What is the vin number of this vehicle?
How is this vehicle used?
Please select the vehicle type for this vehicle.
Please upload two interior and two exterior photos showing all sides of this vehicle. *
Loss Payee
Is this vehicle leased or financed? *
What is the name of the leasing company?
What is address of the leasing company?
What is the name of the financing company?
What is the address of the financing company?
Additional Insured
Is there an additional insured?
What is the name of the additional insured?
What is the address of the additional insured?
Additional Information
Is this vehicle used as a primary residence?
Is this vehicle the only vehicle in the household?
Do you currently own or rent a home?
What is the address of your home/rental?
Do you currently have a Homeowners/Tenant policy?
Do you currently use a mail forwarding service?
Is or will this vehicle be rented or leased to others?
Please describe the method you use to rent or lease this vehicle. (Ie. website, app name, etc.)
Is or will this vehicle be used strictly for recreational purposes?
Is or will this vehicle be used in connection with any operators business or profession?
Is this vehicle a converted school or public transit bus?
Is this vehicle owned by two or more individuals residing in separate households?
Does any operator have a significant mental or physical impairment?
What is the estimated annual mileage?
Discounts
Do you belong to any RV Associations?
Please enter the RV Associations you belong to.
Do you belong to a manufacturer’s club?
Please enter the name of the manufacturer’s club you belong to.
Does this vehicle have an audible alarm?
Have you or any operators taken an approved safety course?
Do any operators have a commercial driver's license (CDL)?
Is this vehicle kept in a garage?
Does this vehicle have a hail proof roof?
Does this vehicle have fiberglass construction?
Coverage Options
Do you require more than $1,000 of coverage for personal property?
What coverage amount is needed to replace your personal property?
Please select the coverages you would like to include on this policy
What coverage amount is needed to cover your valuable personal property (ie. Jewelry, Art, etc.)
Claim Information
Have you had any accidents/claims in the past three years? *
Please provide the requested details for all accidents/claims from the past three years.
Documents and Comments
Please use this field to upload any relevant insurance documents.
Please enter any additional remarks in the space below.
How did you hear about us?
Please share who referred you to us.
Please share what you typed into Google.
Please share how you heard about us.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
