MN Minnesota Motor Home RV Insurance Quote Rate Request Crystal, New Hope, Brooklyn Park AAA, Allied, Auto Owners, Progressive, Kemper

www.insuremn.com

Michael W. Smith Agency

Revised:

May 06, 2015

763-535-7293

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	Please complete the form carefully. If you have credit problems, tell me about it in the comments box. The first 8 digits of the VIN are used to determine the make and model of your vehicle.

MN Motor Home / RV
Insurance Quote Request Form

Motor Home

This is a request for a Minnesota Motor Home insurance quote, not a policy application. Submitting this form does not obligate you to purchase any motor home insurance products. Please complete this form as accurately as possible. Motor home insurance rates are subject to change.

Representing the following motor home insurance companies: AAA, Allied, Auto Owners, Encompass, Foremost, Kemper, Midwest Family Mutual, Progressive & Western National.

General Information

Name
Street
City, State ZIP
Phone
E-mail
FAX

Underwriting Information

Primary Residence
Months at Address
Primary Residence Insurance
Are You a Current Member of the Auto Club (AAA)?	Yes No

Current Motor Home Insurance Information

Current Insurance Company
Expiration Date
Months With Company
Current Bodily Injury Limit

Driver Information (please list all drivers)

Driver #1
Name	Birthdate	Sex	Marital Status

Social Security #		Drivers License #
Defensive Driver Class (age 55 and older)	YesNo	Reject Work Loss Benefit (option for age 65 and older)	Yes No
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)
Comments

Driver #2
Name	Birthdate	Sex	Marital Status

Social Security #		Drivers License #
Defensive Driver Class (age 55 and older)	YesNo	Reject Work Loss Benefit (option for age 65 and older)	Yes No
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)
Comments

Driver #3
Name	Birthdate	Sex	Marital Status

Social Security #		Drivers License #
Defensive Driver Class (age 55 and older)	YesNo	Reject Work Loss Benefit (option for age 65 and older)	Yes No
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)
Comments

Motor Home Information

Year	Make		Model/Series

Body Style	VIN #		Garaging ZIP Code

Usage		Original Owner
		Yes No
Air Bags	Anti-Lock Brakes		Alarm System
	Yes No		Yes No
Comments

Coverage's

Liability Coverage. (Mandatory) Pays for other people's injuries and damage to their property if you or someone else cause an accident while driving your car. It protects your assets in the event you are held liable for damage to others.
Bodily Injury Liability
Property Damage Liability

Personal Injury Protection (No-Fault Coverage). (Mandatory) If you or passengers in your car are injured in an auto accident, this coverage pays for medical expenses, loss of wages and death benefits.
Personal Injury Protection (medical/economic loss)
Personal Injury Protection Deductible

Uninsured and Underinsured Motorists Coverage. (Mandatory) Pays bodily injury claims if you or your passengers are injured by a negligent uninsured motorist, hit-and-run vehicle or a negligent driver without adequate insurance.
Uninsured/Underinsured Motorist

Comprehensive Coverage. Pays for damage to your motor home caused by theft, fire, windstorm, glass breakage and many other non-collision occurrences. Collision Coverage. If your motor home collides with another vehicle or object, this coverage pays to repair your motor home.
Comprehensive Deductible	Collision Deductible	Full Glass	Towing & Labor
		Yes No

Personal Effects - protects the insured's personal items including cameras, clothes, cell phones, etc.
Enter the amount of coverage needed to replace your personal effects	$

Comments

Number of Hits Since August 15, 1998


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