RV Questionnaire

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Full Name(Required)

Home Address

Phone Number

Email Address(Required)

Please provide the following information for EACH DRIVER:

Full Name

Date of Birth

Marital Status

Driver's License Number

Years RV Operating Experience

Safety Course Taken (Type & Date)

Auto & recreational vehicle accidents, tickets, claims & violations in 5 years

Please provide the following information for EACH VEHICLE:

Type

Year, Make & Model

Body Style/Length

VIN Number

Value (Current Market Value OR Purchase Price Value including tax & title fees)

Primary Driver

Safety Features

Permanently Attached Features

Describe Existing Damage

Annual Usage

Parked in a single location year round?

Yes

If yes, address & county

Garaging Zip Code

Purchase Year

Current Insurance Information

List ALL Coverages

Loss Settlement Type

If not insured, please list reason & date coverage went out of force

Additional Information

Do you own a home or rent?

Is the RV ever rented to others?

Additional Insured

Do you have other "toys" that you would like to discuss coverage on?

If you have a copy of your current "Declaration Page", please forward that to us as proof of prior coverage and to use for comparison purposes. Submission of information for a quote in no way binds coverage. Personal information will be used solely for underwriting purposes. Submission of information gives the Gary J Bach Agency permission to run all reports necessary to quote accurate insurance premiums.