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Michael W. Smith Agency

Revised:

May 06, 2015

Motor Home

 763-535-7293

 

 

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Information

 

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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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
 $       

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Comments

 

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Number of Hits Since August 15, 1998

 

 

 

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Copyright 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009 Michael W. Smith Agency