Motorhome/RV QuoteTo complete this quote form, you should know the following:Name, date of birth, martial status, gender, driver’s license number, violations, and accidents for each person on your policyYear, make, model, VIN number, and driving purpose for the vehicle Vehicle specificationsAmount of insurance desired (explanations provided within the form) Driver 1 Information First Name * Middle Initial * Last Name * Email * Phone Number * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Male Female Date of Birth * MM DD YYYY Marital Status * Married Divorced Widowed Single Student Student B average or better College Grad Driver's License Number * Any automobile accidents in the last 3 years? * Yes, at fault Yes, not at fault No If yes, what was the date? MM DD YYYY Any minor violations in the last 3 years? * Examples include a speeding ticket, seat belt violation, issues with registration/titling/licensing Yes No If yes, what was the date? MM DD YYYY Any major violations in the last 5 years? * Examples include DUI, DWI, reckless driving Yes No If yes, what was the date? MM DD YYYY Driver 2 Information (if applicable) If there is only one driver, please skip this and move onto the Vehicle Information section. First Name Middle Initial Last Name Gender N/A Male Female Date of Birth MM DD YYYY Marital Status N/A Married Divorced Widowed Single Student Student B average or better College Grad Driver's License Number Any automobile accidents in the last 3 years? Yes, at fault Yes, not at fault No If yes, what was the date? MM DD YYYY Any minor violations in the last 3 years? Examples include a speeding ticket, seat belt violation, issues with registration/titling/licensing Yes No If yes, what was the date? MM DD YYYY Any major violations in the last 5 years? Examples include DUI, DWI, reckless driving Yes No If yes, what was the date? MM DD YYYY Vehicle Information Date Purchased * MM DD YYYY Year Built * Make and Model * VIN Number * On many motorhomes, you can find the VIN Number just above the bottom edge of the driver's side of the dashboard, just under the windshield. Number of Slide Outs * Is the vehicle made of fiberglass? * Yes No Is the vehicle equipped with an auto tire pressure monitoring system? * Yes No What do you use the vehicle for? * Pleasure, < 30 days per year Pleasure, 30-50 days per year Full time, seasonal use Full time, non-traveling Is your vehicle equipped with any of these safety devices? * None Fire suppression system Spartan Chassiss fire suppression system LP gas detection with auto shutoff Insurance Information Do you have any policies with Nationwide? * Select all that apply. No Auto Commercial Home Life and/or Annuity Boat What is your primary residence? * Homeowner Condo Mobile home Rent home Rent apartment Rent mobile home Is the vehicle currently insured? * Yes No Coverage Desired Please answer the following questions to the best of your ability. If you're unsure of anything, feel welcome to contact us. Bodily Injury Coverage * This coverage helps pay for another person's injuries or damage when you are at-fault in an accident. The first number is the maximum amount that will be paid out to any one individual. The second number is the maximum amount that will be paid out to a group of people (if applicable). The third number is the maximum amount that will be paid out for property damage. The amount of coverage you carry should be enough to protect your assets in the event of an accident. These values are listed in thousands of dollars. 25/50/20 50/100/25 100/300/50 100/100/100 100/300/100 300/300/100 300/300/300 250/500/100 500/500/100 500/500/250 500/500/300 500/500/500 Un-insured/Under-insured Motorist Bodily Injury Coverage * This coverage protects you and the insured members of your household/your passengers for injuries, damage, or death caused by an at-fault driver who either does not have insurance does not have enough insurance. The first number is the maximum amount that will be paid out to any one individual. The second number is the maximum amount that will be paid out to a group of people (if applicable). The amount of coverage you carry should be enough to protect your assets in the event of an accident. These values are listed in thousands of dollars. 25/50 50/100 100/300 300/300 250/500 500/500 Un-insured Motorist Property Damage Coverage * This coverage pays for damage caused to your vehicle if it is hit by an un-insured or under-insured driver. This coverage is only necessary if you do not have Collision Coverage. These values are listed in thousands of dollars. None 15 20 25 Medical Coverage * Medical coverage helps pay for your or your passenger's medical expenses if injured in an accident, regardless of who is at fault. $1,000 $2,500 $5,000 $10,000 Comprehensive Deductible * This is the amount you will pay after filing a claim before the insurance coverage kicks in. Comprehensive coverage includes things outside of an accident (tree falling on car, vandalism, stolen car, etc.) $250 $2,500 $5,000 $10,000 I do NOT want comprehensive coverage Collision Deductible * This is the amount you will pay after filing a claim before the insurance coverage kicks in. Collision coverage protects YOUR car for collisions (rear-ending someone, drive into a tree, hit a fence, etc.) $250 $2,500 $5,000 $10,000 I do NOT want collision coverage Personal Effects Coverage * Provides protection against losses related to items that are not permanently attached to your vehicle (up to $99,000). $ Custom Equipment Coverage * $ Vacation Liability Coverage * Vacation Liability provides coverage when the vehicle is parked off of the road. For example, at a camp ground. $10,000 $25,000 $50,000 $100,000 $250,000 $300,000 $500,000 I do not want Vacation Liability coverage Roadside Assistance Coverage * $750 $2,000 I do not want Roadside Assistance Awning Replacement Coverage * Yes, with sensor Yes, without sensor I do not want awning replacement coverage Additional comments or questions Thank you for requesting a quote from Michael Logue Insurance. We will be in touch with the quote within 1 business day.
