Recreational Insurance
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MOTORHOME INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain a quote on a Motorhome insurance policy. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Garaging Information
What is your name?
Last
First
Middle
What is the garaging address?
Street
City
State
Zip
What is your telephone number?
Home
Work
What is your fax number?
Fax
What is your email address?
Email
Mailing Address
What is your mailing address? (if different from above)
Street
City
State
Zip
Driver Information
Driver 1
First Name
Last Name
Gender
Male
Female
Birth Date
Marital Status
Years Licensed
State Licensed
Occupation
Driver 2
First Name
Last Name
Gender
Male
Female
Birth Date
Marital Status
Years Licensed
State Licensed
Occupation
Driver 3
First Name
Last Name
Gender
Male
Female
Birth Date
Marital Status
Years Licensed
State Licensed
Occupation
Driver 4
First Name
Last Name
Gender
Male
Female
Birth Date
Marital Status
Years Licensed
State Licensed
Occupation
Vehicle Information
Vehicle 1
Year
Make
Model
VIN Number
Cost New Value
Vehicle Type
Length

Miles per year
Ownership
Vehicle 2
Year
Make
Model
VIN Number
Cost New Value
Vehicle Type
Length

Miles per year
Ownership
Vehicle 3
Year
Make
Model
VIN Number
Cost New Value
Vehicle Type
Length

Miles per year
Ownership
Vehicle 4
Year
Make
Model
VIN Number
Cost New Value
Vehicle Type
Length

Miles per year
Ownership
Violation Information
Last 3 years (minor violations)
Last 5 years (major violations)
  Driver 1 Driver 2 Driver 3 Driver 4
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless, hit and run, etc.
Coverage Information
  Bodily Injury Property Damage
Personal liability
Uninsured motorist
Medical payment  
Deductible Information
Vehicle 1
Comprehensive (Theft)
Collision
Vehicle 2
Comprehensive (Theft)
Collision
Vehicle 3
Comprehensive (Theft)
Collision
Vehicle 4
Comprehensive (Theft)
Collision
Miscellaneous Information
Is the Motorhome used as a primary residence?
Primary Residence
Yes No
Is the Motorhome the only vehicle in the household?
Only Vehicle
Yes No
Do you currently own a home?
Homeowner
Yes No
Do you currently have a Motorhome policy?
Current Motorhome Policy
Yes No
Is or will the Motorhome be rented or leased?
Rent or Lease
Yes No
Is or will the Motorhome be used strictly for recreational purposes?
Strictly Recreational Purposes
Yes No
Is or will the Motorhome be used in connection with any operator's business or profession?
Used for Business
Yes No
Is the Motorhome a converted school or public transit bus?
Converted Bus
Yes No
Is the Motorhome owned by two or more individuals residing in separate households?
Owned by Two or More Individuals Residing in Separate Households
Yes No
What is the estimated annual mileage?
Annual Mileage
In which state is or will the Motorhome be registered in?
State Registered
Current Insurance Company
Expiration date
Current premium
Questions or comments
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
Wm.Scott Carter Insurance Agency #0703360

1820 W Carson St. Ste 221 | Torrance, CA 90501
Phone 310-732-0023
Fax 866-234-0026
 
The purpose of this paragraph is to allow the agent to present a customized disclaimer notice. The notice may present the agent's state license and is optional and generated by the agent.

 
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