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RECREATIONAL VEHICLES

Name: Home Telephone #:
Address: E-Mail Address:
City: State: Zip: Best time to reach you? AM     PM
General RV Information
Type: Make:
Model: Year:
Length: Annual Mileage:
Date Purchased:  Purchase Price (including add-on
equipment and taxes)
Is the Motor Home used as a primary residence?     Yes No
Where is your RV principally located? Address:
  City: State:  Zip Code:
   
 
In what state is your RV registered? Is your RV titled in the name of a business?
Is your RV used in connection with any business or profession? Do you share ownership of your RV with anyone other than a spouse?
Current RV insurance company:  Current Policy expiration date:
Specific Information (Answer these two questions only if you own a TRAVEL TRAILER or FIFTH WHEEL.)
Is it permanently parked? Is it used as a primary residence?Yes No
Specific Information (Complete this section only if you own a MOTOR HOME.)
Drivers’ names as they appear on licenses   Date of birth % of time each drives the motor home
 
Describe any accidents, moving violations, or drivers' license suspensions/restrictions for the past three years for each driver: Where did it happen? Date it occurred Were you at fault?
 
Has the principal driver owned or driven any motor home more than 12 months?
Is any driver required by a state to file proof of financial responsibility?
Has any driver had motor vehicle insurance coverage refused or canceled within the past three years?
Is the motor home a converted school or public transit bus, step van or delivery vehicle?
 

 

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