Le Claire Insurance

J L Le Claire & Sons Insurance Agency

The Protection and Security you would expect from Family

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Motorhome Quote

Motorhome Insurance Quote Request Complete the following information if you would like to obtain a quote. Please understand this is not an application. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Named Insured
Last Name
First Name
Street Address
City
State
Zip Code
Phone Number
Fax Number
Email Address
Date of Birth
Social Security Number
Garaging/Storage Address - if different from above
Name of Location (If Storage Facility)
Street Address
City
State
Zip Code
Driver 1 Information
First Name
Last Name
Gender	Male Female
Birth Date
Marital Status
Years Licensed
State Licensed
Relationship to Named Insured
Driver 2 Information
First Name
Last Name
Gender	Male Female
Birth Date
Marital Status
Years Licensed
State Licensed
Relationship to Named Insured
Driver 3 Information
First Name
Last Name
Gender	Male Female
Birth Date
Marital Status
Years Licensed
State Licensed
Relationship to Named Insured
Driver 4 Information
First Name
Last Name
Gender	Male Female
Birth Date
Marital Status
Years Licensed
State Licensed
Relationship to Named Insured
Vehicle 1 Information
Year
Make
Model
Vin #
Cost New Value
Vehicle Type
Length
Miles per Year
Loss History
Ownership
Vehicle 2 Information
Year
Make
Model
Vin #
Cost New Value
Vehicle Type
Length
Miles per Year
Loss History
Ownership
Vehicle 3 Information
Year
Make
Model
Vin #
Cost New Value
Vehicle Type
Length
Miles per Year
Loss History
Ownership
Vehicle 4 Information
Year
Make
Model
Vin #
Cost New Value
Vehicle Type
Length
Miles per Year
Loss History
Ownership
Violation Information - Last 3 years (minor violations) / Last 5 years (major violations)
Driver 1
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 2
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 3
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Driver 4
Minor Violations - speeding, turn, stop sign, red light, etc.
Accidents - chargeable
Major violations - drunk driving, reckless,hit and run, etc.
Coverage Information
Bodily Injury
Property Damage
Uninsured Motorist / Underinsured Bodily Injury
Uninsured Motorist / Property Damage
Medical Payments
Adjacent Structures, i.e. Awnings. Satellite, etc. (Amount)
Vacation Liability
Towing/Roadside Assistance
Emergency Expense
Scheduled Medical Benefits (Amount)
Personal Property Amount (Actual Cash Value)
Personal Property Replacement Cost	Yes No
Total Loss Replacement Cost	Yes No
Are you the Original Owner of the Unit	Yes No
Full Timer Liability
Additional Living Expense (Only available with Full Timer Liability)
Deductible Information
Vehicle 1
Comp (theft)
Collision
Vehicle 2
Comp (theft)
Collision
Vehicle 3
Comp (theft)
Collision
Vehicle 4
Comp (theft)
Collision
Miscellaneous Information
Is the Motorhome used as a primary residence?	Yes No
Is the Motorhome the only vehicle in the household?	Yes No
Do you currently own a home?	Yes No
Do you currently have a Motorhome policy?	Yes No
Is or will the Motorhome be rented or leased?	Yes No
Is or will the Motorhome be used strictly for recreational purposes?	Yes No
Is or will the Motorhome be used in connection with any operator's business or profession?	Yes No
Is the Motorhome a converted school or public transit bus?	Yes No
Is the Motorhome owned by two or more individuals residing in separate households?	Yes No
What is the estimated annual mileage?
In which state is or will the Motorhome be registered in?
Current Insurance Company
Expiration Date
Current Premium
Questions or Comments

Motorhome Insurance Quote Request

Named Insured

Garaging/Storage Address - if different from above

Driver 1 Information

Driver 2 Information

Driver 3 Information

Driver 4 Information

Vehicle 1 Information

Vehicle 2 Information

Vehicle 3 Information

Vehicle 4 Information

Violation Information - Last 3 years (minor violations) / Last 5 years (major violations)

Driver 1

Driver 2

Driver 3

Driver 4

Coverage Information

Deductible Information

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Miscellaneous Information