Insurance Coverage Quote Request

Step 1: Print this form    Step 2: Complete and fax to 1-818-735-6778

Principal Operator______________________________Date of Birth________________

Additional Operator_____________________________Date of Birth________________

Street Address__________________________________________________________

City___________________________________State_________Zip________________

Phone (_______)___________________________        (Circle One)   Married    Single

Are you a homeowner? Yes No
Will your RV be used for recreational purposes only? Yes No
Will you be using your RV as a full-time residence? Yes No
If Travel Trailer: For permanent stationary use only? Yes No
If stationary, provide address here ->    
Will your RV be used in connection with business? Yes No
Discount: Are you a member of an RV Association? Yes No
Any tickets or at-fault accidents in the last 3 years? Yes No

(Circle One)   Motor Home    Travel Trailer    Camper Van    5th Wheel    Truck Mounted Camper

Year__________Length________Make/Model_________________________________

Market Value: $________________Original Purchase Price: $_____________________

Circle the Deductible Option You Prefer:
                                                                   $250     $500     $1000     $2500

(Motor Home Only) Liability Limits You Prefer:
                                                                   $100/300/50     250/500/100     $1 Million


Name of your RV Dealer___________________________Your fax number (_______)____________________

Fax this form to 818-735-6778 and you’ll receive a quotation by fax within 30 minutes.
Call today for an immediate quotation… 800-400-0186.