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Phone Number *
Marital Status * Married Widowed Single
RV Coverage Other
Years RV Operating Experience
Email Address *
RV Type * Motor Home - Class A Motor Home - Class B Motor Home - Class C Motor Home - Bus Conversion Motor Home - Toter Home Travel Trailer - Conventional Travel Trailer - Pop-Up Travel Trailer - Fifth Wheel Travel Trailer - Truck Camper
Year *
Manufacturer *
Model/Series *
Body Style
Value of RV (Purchase Price) *
Length of Ownership
Garaging ZIP Code *
Primary Residence * RV (Full Timer) Own a Home/Condo Own a Mobile Home Rent Live with Parents Other
Multi Owner Names
Prior Carrier
Physical Damage Deductibles $250 $500 $1,000 $2,500
Liability Coverage Limits (Motor Home Only) State Minimum 25/50 50/100 100/300 250/500
UM/UIM Coverage Limits None 25/50 50/100 100/300 250/500
Medical Payments Coverage $1,000 $2,500 $5,000 $10,000
Emergency Expense Coverage $750 (included with Physical Damage) $2,000 $7,500 (Full Timer's only)
Vacation Liability ($10,000 included—up to $500,000)
Personal Effects Coverage ($1,000 – $99,000)
Full-Timers Package Not Applicable $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $300,000 CSL $500,000 CSL
Additional Utility Trailer Coverage (Motor Home only)
Additional Comments or Special Circumstances