First
name*
MI
Last
name*
Address
*
City*
State*
Select
MO
IL
Zip*
Marital
Status
Select
Single
Married
Divorced
Widowed
Other
Best
way to be contacted?*
Select
e-mail
phone call
letter
fax
Phone
number (add area code)*
Best
time to call*
a.m.
p.m.
Fax
number
Work
number
E-mail
address *
Occupation
How
long
Select
Years
Months
Additional
Comments:
Driver Information
Current
Status of Driver's License
Select
Valid
Permit
Suspended
Not Licensed
Number
of Drivers?
Select
One
Two
More
Number
of years driving a motor home
Are
you currently insured?
Select
Yes
No
If
insured, name of insurance carrier:
Number
of at-fault accidents in the last 3 years
Number
of minor traffic violations in the last 3 years
Number
of major traffic violations in the last 3 years
Have
you completed a state approved driver
Select
Yes
No
Do
you have any bankruptcies, tax liens, judgments, foreclosured
or repossissions?
Select
Yes
No
Vehicle
Information
Model
Year
Description
of motor home
Select
Professional Bus
Conversion
Camper Van
Mini Motorhome
Converted School Bus
Make
Select
Allegro
Airstream
Avion
Barth
Bounder
Champion
Chevrolet
Coachman
Dodge
Eldorado
Fleetwood
Ford
GM
Gulf Stream
Holiday
Honey
Itasco
Jayco
Mallard
Midas
National
Newell
Overland
Pace-Arrow
Prowler
Shasta
Southwind
Starcraft
Tioga
Vogue
Winnebago
Other
Model
Type
of Use
Select
Business/Commerical
Use
Only Vehicle in
Household
Driving to/From Work
Rented/Leased to Others
Transient/Migratory/Seasonal
Risk
Used as Primary
Residence
Pleasure
Is
your motor home equipped with audible
Select
Yes
No
Is
the motor home co-owned?
Select
Yes
No
Value
of motor home
Value
of personal effects
$
Select
1000-5000
5000-10000
10000-15000
15000-20000
20000-25000
25000-30000
30000-35000
35000-40000
40000-45000
45000-50000
Is
the motor home used as a primary residence at least 150 days
a year?
Select
Yes
No
Coverage Information
Liability
Coverages
Select
Low Limits
Medium Limits
High Limits
Coverage
Packages
Select
Liability
ONLY (selected above)
Full Coverage
Full
Coverage Options
Select
Full Coverage Package Options
Total Loss Replacement
Actual Cash Value
Optional
Coverages
Select
Uninsured Moterists Property Damage
Medical Payments $5,000 limit
Emergency Expense $750 Max/No Per Day
Vacation Liability $10,000 Limit
Deluxe Package Diminishing Deductibles and Scheduled Medical Benefits
