RV Questionnaire Full Name (First, MI, Last): Home Address: Phone Number Email Address 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 —Please choose an option—Class A RVClass B RVClass C RVBus ConversionTravel TrailerPop-UpFifth WheelTruck CamperToy HaulerUtility Hauler Year Make Model Body Style/Length VIN # Value (Current Market Value OR Purchase Price Value including tax & title fees) Primary Driver Safety Features Permanently Attached Features Describe Existing Damage Annual Usage —Please choose an option—<30 days30-150 days>150 daysPrimary Residence Parked in a single location year round? YesNo If yes, address & county Garaging Zip Code Purchase Year Current Insurance Info: Current Insurance Company & Due Date List ALL Coverages (BI/PD | Comp Deductible | Med Pay | Collision Deductible | UM/UIM BI | UMPD | Vacation Liability | Personal Effects | Other Coverages) Loss Settlement Type —Please choose an option—Total Loss ReplacementAgreed ValueACV If not insured, please list reason & date coverage went out of force Additional Info: 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.
