R.V. Quote Sheet

Applicant Information

Name

Address

City

State

ZIP

E-Mail

Phone Number

Best time to call

What type of Recreational Vehicles (RV) Boat Motorcycle ATV Jet Ski Snowmobile

How many Recreational Vehicles do you own? 1 2 3 4 5

How many drivers in your household? 1 2 3 4 5

Do you have insurance on your RV now? Yes No

If Yes, with Whom?

Expires (mo/yr)

How many years of operating experience do you have?

Is RV garaged? Yes No

What is the operating base (cost) of RV?

Vehicle Information

RV 2

Year

Make

Model

CC's or Horsepower

Coverages: Liability 25/50/15 25/50/25 50/100/50 100/300/50 100/300/100 250/500/250 N/A

PIP 3000 5000 10000 N/A

Comprehensive Deductible 0 50 100 200 250 500 1000 N/A

Collision Deducible 100 200 250 500 1000 N/A

RV 4

Year

Make

Model

CC's or Horsepower

Coverages: Liability 25/50/15 25/50/25 50/100/50 100/300/50 100/300/100 250/500/250 N/A

PIP 3000 5000 10000 N/A

Comprehensive Deductible 0 50 100 200 250 500 1000 N/A

Collision Deducible 100 200 250 500 1000 N/A

Driver Information

Driver 1

Name

Date of birth: Mo Day Year

Vehicle Driven

Rider Group or Membership Discount

Driver 3

Name

Date of birth: Mo Day Year

Vehicle Driven

Rider Group or Membership Discount

Driver 5

Name

Date of birth: Mo Day Year

Vehicle Driven

Rider Group or Membership Discount

Are there any other people living in your household who are not listed as drivers(i.e. children, girlfriend, boyfriend, etc.)? Yes No

If yes, list names and birthdates.