Personal Data
Last Name
First
Address
City
State
New York
Zip Code
Phone
Fax (optional)
E-Mail (Required)
Marital Status
Currently Insured
Date of Birth XX/XX/XXXX
Social Security #
RV Information
Type
Select One
Motor Home
Travel Trailer
Fifth-Wheel
Pop-up Camper
Truck-Mounted Camper
Make
Model
Year
Length
Date Purchased
Purchase Price (incl. add. eqpt. and taxes)
$
Is the RV used as a primary residence?
Where is your RV principally located?
Select One
Same address as above
At the address below
NYS only
Address
City
State
New York
Zip Code
Is your RV registered in New York?
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
If you own a Travel Trailer or Fifth Wheel, is it permanently parked?
Driver Information Only if you own a motor home
Driver name as it appears on drivers license
License #
Date of birth
Social Security #
Driver name as it appears on drivers license
License #
Date of birth
Social Security #
Driver name as it appears on drivers license
License #
Date of birth
Social Security #
In the area below please describe any accidents, moving violations or drivers' license
suspensions / restrictions for the past three years for each driver.
Has the principal driver owned or driven any motor home more than 12 months?
Has any driver had motor vehicle insurance coverage refused or cancelled within
the past three years?
Is the motor home a converted school or public transit bus, step van or delivery
vehicle??
Coverage
Limit of Liability (listed in thousands)
Select One
$50/100 BI/50 PD
$100/300 BI/50 PD
$250/500 BI/100 PD
PIP
Select One
$50,000
$75,000
$100,000
$150,000
Sum
Select One
25/50
50/100
100/300
250/500
Comprehensive & Collision
Select One
No Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
OBel
Towing
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