MOTOR HOME INSURANCE

MOTOR HOME

INSURANCE

Complete the following information if you would like to obtain a quote on a Motor Home 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:

1. Business Name:

2. Business Address:

3. Mailing Address (if different:

City: State: Zip:

4. Contact Person: Person is: FORMCHECKBOX Owner FORMCHECKBOX Manager

FORMCHECKBOX Promoter FORMCHECKBOX Mgmt FORMCHECKBOX Other:

5. Phone: Fax #: E Mail:

DRIVER INFORMATION:

Driver #1:

Name: Gender: FORMCHECKBOX Male FORMCHECKBOX Female

Birthdate: Marital Status: Occupation:

Years Licensed: State Licensed:

Driver #2:

Name: Gender: FORMCHECKBOX Male FORMCHECKBOX Female

Birthdate: Marital Status: Occupation:

Years Licensed: State Licensed:

Driver #3:

Name: Gender: FORMCHECKBOX Male FORMCHECKBOX Female

Birthdate: Marital Status: Occupation:

Years Licensed: State Licensed:

Driver #4:

Name: Gender: FORMCHECKBOX Male FORMCHECKBOX Female

Birthdate: Marital Status: Occupation:

Years Licensed: State Licensed:

VEHICLE INFORMATION:

Vehicle #1:

Year: Make: Model: Vin#

Cost New Value: $ Vehicle Type: Length:

Miles per year: Ownership:

Vehicle #2:

Year: Make: Model: Vin#

Cost New Value: $ Vehicle Type: Length:

Miles per year: Ownership:

Vehicle #3:

Year: Make: Model: Vin#

Cost New Value: $ Vehicle Type: Length:

Miles per year: Ownership:

Vehicle #4:

Year: Make: Model: Vin#

Cost New Value: $ Vehicle Type: Length:

Miles per year: Ownership:

VIOLATION INFORMATION:

Last three (3) years (minor violations). Last five (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 & run, etc.

COVERAGE INFORMATION:

	Bodily Injury	Property Damage
Personal Liability Limits
Uninsured Motorist Limits
Medical Payment Limits

DEDUCTIBLE INFORMATION:

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Comprehensive (Theft)
Collision
Comprehensive (Theft)
Collision
Comprehensive (Theft)
Collision
Comprehensive (Theft)
Collision

MISCELLANEOUS INFORMATION:

Is the Motor Home used as a primary residence?	Primary Residence	FORMCHECKBOX Yes FORMCHECKBOX No
Is the Motor Home the only vehicle in the household?	Only Vehicle	FORMCHECKBOX Yes FORMCHECKBOX No
Do you currently own a home?	Homeowner	FORMCHECKBOX Yes FORMCHECKBOX No
Do you currently have a Motor Home policy?	Current Motor Home Policy	FORMCHECKBOX Yes FORMCHECKBOX No
Is or will the Motor Home be rented or leased?	Rent or Lease	FORMCHECKBOX Yes FORMCHECKBOX No
Is or will the Motor Home be used strictly for recreational purposes?	Strictly Recreational Purposes	FORMCHECKBOX Yes FORMCHECKBOX No
Is or will the Motor Home be used in connection with any operator’s business or profession?	Used for Business	FORMCHECKBOX Yes FORMCHECKBOX No
Is the Motor Home a converted school or public transit bus?	Converted Bus	FORMCHECKBOX Yes FORMCHECKBOX No
Is the Motor Home owned by two or more individuals residing in separate households?	Owned by Two or More Individuals Residing in Separate Households	FORMCHECKBOX Yes FORMCHECKBOX No
What is the estimated annual mileage?	Annual Mileage	________________
In which state is or will the Motor Home be registered in?	State Registered	________________

Current Insurance Company:
Expiration Date:	Mo: Day: Yr:
Current Premium:	$
Questions or Comments:

Please let us know the best time to call and discuss your quote:

FORMCHECKBOX Morning FORMCHECKBOX Afternoon FORMCHECKBOX Evening FORMCHECKBOX Anytime FORMCHECKBOX Other:

STATE LICENSED AGENT

F. DARRELL LINDSEY – ALL STATES

P. O. Box 526357

Salt Lake City, UT 84152-6357

PH: 801-937-7037

FX: 800-694-6363

E-Mail: fdl@LLLindsey.com

California Office License No#: OC13511 – Robby L. Lindsey