MOTOR HOME INSURANCE; TRAVEL TRAILER: Motor home, mini motor home, camper van, travel trailer, pop-up camper, fifth-wheel camper and mounted camper used for personal use not related to a business and registered to you or a family household family member. Please complete the Motor Home Worksheet below to receive an insurance proposal.We have other insurance program worksheets you can select from the InsuranceCompany.com main menu option or clicking on the InsuranceCompany.com logo to the right. You can get an auto insurance proposal by selecting the auto option. If the auto is a business use vehicle please select the business auto option. If the vehicle is a large size (2 1/2 ton or more) commercial use type please select the commercial vehicle option.

MOTOR HOME WORKSHEET
First Name:
Last Name:
Garaging Address:
Garaging City:
Garaging State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming
Garaging Zip Code:
Phone Number:
Fax Number:
E-Mail Address:

MAILING ADDRESS (optional)
Mailing Address If Different from Garaging:
Mailing City:
Mailing State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming
Mailing Zip Code:

DRIVER INFORMATION
	Driver One	Driver Two	Driver Three	Driver Four
First Name
Birthdate
Sex	Male Female	Male Female	Male Female	Male Female
Marital Status	Single Married Divorced Widowed Separated	Single Married Divorced Widowed Separated	Single Married Divorced Widowed Separated	Single Married Divorced Widowed Separated
Yrs Licensed
State Licensed
Occupation

VEHICLE INFORMATION
	Vehicle 1	Vehicle 2
Year
Make
Model
Vehicle Type	Camper Van Pop-Up Camper Mounted Camper Travel Trailer Mini Mtr Home Fifth-Wheel Motor Home	Camper Van Pop-Up Camper Mounted Camper Travel Trailer Mini Mtr Home Fifth-Wheel Motor Home
I.D. #
Cost New Value
Miles Driven Each Year	Under 5,000 5,000-9,999 10,000-14,999 15,000-19,999 20,000-24,999 30,000-34,999 35,000-39,999 40,000-44,999 45,000-49,999 50,000+	Under 5,000 5,000-9,999 10,000-14,999 15,000-19,999 20,000-24,999 30,000-34,999 35,000-39,999 40,000-44,999 45,000-49,999 50,000+
Ownership	Leased Paid-Off Financed	Leased Paid-Off Financed

VIOLATION INFORMATION
Last 3 Yrs (Minors) Last 5 Yrs (Majors)	Driver 1	Driver 2	Driver 3	Driver 4
Minor Violations - Speeding, Turn, Stop Sign, Red Light, etc.	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4
Accidents - Non Chargeable	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4
Accidents - Chargeable	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4
Major Violations - Drunk Driving, Reckless, Hit & Run, etc.	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4

COVERAGE INFORMATION
	Bodily Injury	Property Damage
Personal Liability	15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000	5,000 10,000 25,000 50,000 100,000
Uninsured Motorist	None 15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000	None 3,500 Deductible Waiver
Medical Payment:	No Coverage 1,000 2,000 2,500 5,000 10,000 15,000 20,000 25,000 50,000 100,000

DEDUCTIBLE INFORMATION
	Vehicle 1	Vehicle 2
Comprehensive (Theft)	No Coverage 250 500 1,000 1,500 2,000	No Coverage 250 500 1,000 1,500 2,000
Collision	No Coverage 250 500 1,000 1,500 2,000	No Coverage 250 500 1,000 1,500 2,000

MISC INFORMATION
Current Insurance Company:
Expiration Date:
Current Premium $:
Questions or Comments to help the Agent:
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