1 Drivers2 Vehicles3 Underwriting4 Coverage Driver InformationOwner/Driver's First Name*Owner/Driver's Last Name*Gender*Choose One...MaleFemaleBirth Date of Primary Driver* Marital Status*Choose One...SingleMarriedDivorcedWidowedHow many years of RV/Travel Trailer operation experience does the principle driver have?*Choose One...Less than 1 Year12345678910More than 10 YearsHave you owned a motorhome or travel trailer for over 2 years?*YesNoIs the RV registered to an LLC?*YesNoNot all carriers will insure RV's owned by LLCs or corporations.Will your spouse drive the insured vehicle?*YesNoSpouse Name* First Last Birth Date of Spouse* Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Vehicle InformationIs the registration address the same as the mailing address?*YesNoRegistration Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the garaging address the same as the mailing address?*YesNoGaraging Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Garaging County*Vehicle Type*Choose One...Motor HomeTravel TrailerMotor Home Type*Choose One...Class AClass BClass CProfessional Bus or Heavy Truck ConversionTrailer Type*Choose One...Conventional Travel TrailerFifth WheelWill the unit be stationary?*YesNoYear*Make (e.g. Winnebago)*Model (e.g. Adventurer)*Series (e.g. 38R WKHRS)*Vehicle Identification Number (VIN)*Length of Unit*Value of Unit*Restraint Air Bag*Choose One...NoneDriver's SideBoth SidesAnti-Theft Systems Alarm System Active Disabling Electronic Retrieval Passive Disabling Device Daytime Running Lights*YesNoAnti-Lock Brakes*YesNoWas the RV Purchased new or used?*NewUsedDate Purchased* Recreational Use*Choose One...Less than 30 days per year30 to 150 days per yearMore than 150 per yearFull-Timer UnderwritingPrimary Driver's License Number*Driver's License State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPrimary Driver's License Status*Choose One...ValidExpired/CancelledRevokedSuspendedPermitInternational LicenseSecondary Driver's License Number*Secondary Driver's License Status*Choose One...ValidExpired/CancelledRevokedSuspendedPermitInternational LicenseIs the unit ever used in business?*YesNoIs the unit stored in an RV storage Facility and not being used on a regular basis?*YesNoRV Assocation Membership*Choose One...Not ApplicableGood SamsAAA RV PlusCamping World Press ClubCoast to CoastEscapeesFMCAFamily CampersHappy Campers Club, IncOtherRVing WomenThousand TrailsWestern Horizon ResortsDoes the primary driver have any violations in the last five years?*YesNoWhat type was the first violation?*Choose One...Alcohol NON Driving RelatedAlcohol Related ConvictionsCareless drivingDefective equipment, Improper use of lights/signalDriving with suspended/revoked/invalid, unlawful useDrug convictions: Refusing chemical test, DUI: drugsElude or Disobey OfficerFailure to yield, stop, comply, or yield to pedestrianFelony, assault, violation of law resulting in deathFollowing too closely, driving on wrong side/wrong directionHit and run, non-reported accidentIllegal passing, improper passingImproper/Unsafe TurnMinor ViolationMoving violation waived - state mandatedNegligent drivingNon-Chargeable: No Specific Driver - Assign to Named InsProperty protection insurance accidentRacingReckless drivingSpeeding: major over 15 mph over speed limitSpeeding: minor under or equal to 15 mph over speed limitUnlawful Use of License or Regulation, Allow Unlicensed to Drive, or W/O PermitUnlawful use of vehicle, abandon vehicle, major violationsWhen did the violation occur?* What type was the second violation?Choose One...Alcohol NON Driving RelatedAlcohol Related ConvictionsCareless drivingDefective equipment, Improper use of lights/signalDriving with suspended/revoked/invalid, unlawful useDrug convictions: Refusing chemical test, DUI: drugsElude or Disobey OfficerFailure to yield, stop, comply, or yield to pedestrianFelony, assault, violation of law resulting in deathFollowing too closely, driving on wrong side/wrong directionHit and run, non-reported accidentIllegal passing, improper passingImproper/Unsafe TurnMinor ViolationMoving violation waived - state mandatedNegligent drivingNon-Chargeable: No Specific Driver - Assign to Named InsProperty protection insurance accidentRacingReckless drivingSpeeding: major over 15 mph over speed limitSpeeding: minor under or equal to 15 mph over speed limitUnlawful Use of License or Regulation, Allow Unlicensed to Drive, or W/O PermitUnlawful use of vehicle, abandon vehicle, major violationsWhen did the violation occur? Does the secondary driver have any violations in the last five years?*YesNoWhat type was the first violation?*Choose One...Alcohol NON Driving RelatedAlcohol Related ConvictionsCareless drivingDefective equipment, Improper use of lights/signalDriving with suspended/revoked/invalid, unlawful useDrug convictions: Refusing chemical test, DUI: drugsElude or Disobey OfficerFailure to yield, stop, comply, or yield to pedestrianFelony, assault, violation of law resulting in deathFollowing too closely, driving on wrong side/wrong directionHit and run, non-reported accidentIllegal passing, improper passingImproper/Unsafe TurnMinor ViolationMoving violation waived - state mandatedNegligent drivingNon-Chargeable: No Specific Driver - Assign to Named InsProperty protection insurance accidentRacingReckless drivingSpeeding: major over 15 mph over speed limitSpeeding: minor under or equal to 15 mph over speed limitUnlawful Use of License or Regulation, Allow Unlicensed to Drive, or W/O PermitUnlawful use of vehicle, abandon vehicle, major violationsWhen did the violation occur?* What type was the Second violation?Choose One...Alcohol NON Driving RelatedAlcohol Related ConvictionsCareless drivingDefective equipment, Improper use of lights/signalDriving with suspended/revoked/invalid, unlawful useDrug convictions: Refusing chemical test, DUI: drugsElude or Disobey OfficerFailure to yield, stop, comply, or yield to pedestrianFelony, assault, violation of law resulting in deathFollowing too closely, driving on wrong side/wrong directionHit and run, non-reported accidentIllegal passing, improper passingImproper/Unsafe TurnMinor ViolationMoving violation waived - state mandatedNegligent drivingNon-Chargeable: No Specific Driver - Assign to Named InsProperty protection insurance accidentRacingReckless drivingSpeeding: major over 15 mph over speed limitSpeeding: minor under or equal to 15 mph over speed limitUnlawful Use of License or Regulation, Allow Unlicensed to Drive, or W/O PermitUnlawful use of vehicle, abandon vehicle, major violationsWhen did the violation occur? Does the primary driver have any accidents in the last five years?*YesNoWhat type was the first accident?*Choose One...At Fault AccidentNot at fault accidentAt Fault Accident - WaivedWhen did the accident occur?* What type was the second accident?*Choose One...At Fault AccidentNot at fault accidentAt Fault Accident - WaivedWhen did the accident occur? Does the secondary driver have any accidents in the last five years?*YesNoWhat type was the first accident?*Choose One...At Fault AccidentNot at fault accidentAt Fault Accident - WaivedWhen did the accident occur?* What type was the second accident?Choose One...At Fault AccidentNot at fault accidentAt Fault Accident - WaivedWhen did the accident occur? Is the unit ever rented or loaned to others?*YesNoIs the RV your only residence?*YesNoDo you own a home?*YesNoHome Type*HomeApartmentCondoManufactured/Mobile HomeTown Home CoverageEffective Date* The effective date cannot be great than 30 days into the future.Coverage Type*Full CoverageLiability OnlyDeductible Options*Choose One...$100$250$500$1,000$2,000$5,000Bodily Injury Liability*Choose One...$50,000/$100,000$100,000/$300,000$300,000/$300,000$250,000/$500,000$500,000/$500,000Property Damage Liability*Choose One...$50,000$100,000$300,000$500,000Uninsured/Underinsured Motorist Coverage*Choose One...YesNoUninsured/Underinsured Motorist limits will always match the Bodily Injury limits.Medical Payments*Choose One...No Coverage$1,000$2,000$5,000$10,000$25,000Towing and Labor*YesNoPersonal Effects*$1,000$2,000$3,000$4,000$5,000$6,000$7,000$8,000$9,000$10,000Consignment Insurance*YesNoIn order to provide this coverage we will need a copy of the dealership’s consignment agreement faxed to us at 928-779-7221.No impact credit authorization* I agree In connection with this application for insurance, we may review your credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. THIS DOES NOT AFFECT YOUR FICO SCORE, and is not used in all states. However, depending on your state, we may use a third party in connection with the development of your insurance score. We may also obtain loss history and other consumer reports using a third party. The above information may be used to develop your premium or to determine your eligibility for insurance. Providing your social security number is not required at this point, but can help us to obtain a more accurate quote.
