TRAVEL TRAILER

INSURANCE

 

Complete the following information if you would like to obtain a quote on a Travel Trailer 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 Travel Trailer used as a primary residence?

Primary Residence

 FORMCHECKBOX   Yes   FORMCHECKBOX   No

Is the Travel Trailer 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 Travel Trailer policy?

Current Travel Trailer Policy

 FORMCHECKBOX   Yes   FORMCHECKBOX   No

Is or will the Travel Trailer be rented or leased?

Rent or Lease

 FORMCHECKBOX   Yes   FORMCHECKBOX   No

Is or will the Travel Trailer be used strictly for recreational purposes?

Strictly Recreational Purposes

 FORMCHECKBOX   Yes   FORMCHECKBOX   No

Is or will the Travel Trailer be used in connection with any operator’s business or profession?

Used for Business

 FORMCHECKBOX   Yes   FORMCHECKBOX   No

What is the Travel Trailer’s usage?

Usage

 

Is the Travel Trailer 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 Travel Trailer 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