SNOWMOBILE
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: Years Licensed:
State Licensed: Occupation:
Driver #2:
Name: Gender: FORMCHECKBOX Male FORMCHECKBOX Female
Birthdate: Marital Status: Years Licensed:
State Licensed: Occupation:
Driver #3:
Name: Gender: FORMCHECKBOX Male FORMCHECKBOX Female
Birthdate: Marital Status: Years Licensed:
State Licensed: Occupation:
Driver #4:
Name: Gender: FORMCHECKBOX Male FORMCHECKBOX Female
Birthdate: Marital Status: Years Licensed:
State Licensed: Occupation:
VEHICLE INFORMATION:
Vehicle #1:
Year: Make: Model: # of CC’s
Cost New Value: $ Garaged: FORMCHECKBOX Yes FORMCHECKBOX No Years Owned:
Ownership: Describe any Accessories or Special Equipment Including Cost When New:
Vehicle #2:
Year: Make: Model: # of CC’s
Cost New Value: $ Garaged: FORMCHECKBOX Yes FORMCHECKBOX No Years Owned:
Ownership: Describe any Accessories or Special Equipment Including Cost When New:
Vehicle #3:
Year: Make: Model: # of CC’s
Cost New Value: $ Garaged: FORMCHECKBOX Yes FORMCHECKBOX No Years Owned:
Ownership: Describe any Accessories or Special Equipment Including Cost When New:
Vehicle #4:
Year: Make: Model: # of CC’s
Cost New Value: $ Garaged: FORMCHECKBOX Yes FORMCHECKBOX No Years Owned:
Ownership: Describe any Accessories or Special Equipment Including Cost When New:
TRAILER INFORMATION:
Year | Make | Model | Value |
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| $ |
Comprehensive Deductible | Collision Deductible |
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$ | $ |
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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. |
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Accidents – non chargeable |
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Accidents – chargeable |
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Major violations – drunk driving, reckless, hit & run, etc. |
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COVERAGE INFORMATION:
| Bodily Injury | Property Damage |
Personal Liability Limits |
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Uninsured Motorist Limits |
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Medical Payment Limits |
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DEDUCTIBLE INFORMATION:
Vehicle #1
|
Vehicle #2
|
Vehicle #3
|
Vehicle #4
|
Comprehensive (Theft) |
|
Collision |
|
Comprehensive (Theft) |
|
Collision |
|
Comprehensive (Theft) |
|
Collision |
|
Comprehensive (Theft) |
|
Collision |
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MISCELLANEOUS INFORMATION:
Is or will the Snowmobile be rented or leased? | Rent or Lease | FORMCHECKBOX Yes FORMCHECKBOX No | |
Is or will the Snowmobile be used strictly for recreational purposes? | Strictly Recreational Purposes | FORMCHECKBOX Yes FORMCHECKBOX No | |
Is or will the Snowmobile be used in connection with any operator’s business or profession? | Used for Business | FORMCHECKBOX Yes FORMCHECKBOX No | |
What is the estimated annual mileage? | Annual Mileage | ________________ | |
In which state is or will the Snowmobile be registered in? | State Registered |
________________ | |
Current Insurance Company: |
| ||
Expiration Date: | Mo: Day: Yr: | ||
Current Premium: | $ | ||
Questions or Comments:
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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