Recreational Vehicle Quote Form

First Name: (required)
Middle Initial:
Last Name(required):
Email (required):
Telephone Number (required):
Street Address:
City:
State:
Zipcode:
Sex:  Male Female
Date of Birth:
Social Security Number:
Marital Status?  Single Married Other
Driving record (prior 35 months)
Number/nature of tickets (all vehicles):
Number/nature of tickets AF/NAF Auto/RV Accidents:
Automobile Drivers License Status
Primary Residence (discount for Homeownership: includes ownership of Mobile Home if less than 10 years old):  Own Home/Condo Own Mobile Home less than 10 years old Rent Live with my parents other
Mobile Home Travel/Trailer Information
Motor Homes:  Class A Class B Class C Bus Conversion
Travel Trailers:  Conventional Pop-up Fifth wheel Truck Camper
Year:
Make:
Model:
Rating Base:
Garaging Zip:
Anti-Theft Device?  Yes No
Anti-Lock Brakes?  Yes No
Vehicle Use?  Under 30 Days 30- 150 Days Over 150 Days Traveling Not-Traveling
Underwriting Information
Other Progressive Policies (5% Discount)  Automobile Boat Motorcycle RV Snowmobile
Name of Co-Owners:
Names of Regular Operators (Any operator with regular access to the vehicle more than 12 times a year):
Names of household resident operators:
Coverage Information
Physical Damage Coverage?  Total Loss Replacement (new RV's only) Agreed Value Actual Cost Value
Liability Coverage Limits (motor home only):
UM/UIM Coverage Limits (motor home only):
Medical Payments Coverage:
Emergency Expense Coverage:
Vacation Liability ($10,000-$500,000):
Personal Effects Coverage ($1,000-$99,000):
Deluxe Package (Disappearing deductibles & scheduled medical benefits):  Yes No
Roadside Assistance  Yes No
Full-Timers Package  $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $300,000 CSL $500,000 CSL
Traveler's Coverage (up to $20,000, $2,500 coverage included):  Yes No