Step 1 of 5 20% Contact InformationFirst Name*Last Name*Email* Home Phone*Cell PhonePreferred Contact MethodSelect contact methodPhoneEmailNo PreferenceBest Time to ContactMorningAfternoonEveningAnytimeHow did you find us?Passport AmericaEscapeesFMCAMagazineInternetYellow PagesAgentDealerManufacturerFriendRelativeOtherWere you referred by an Agent, Dealer, or Manufacturer?YesNoCompany NamePhone NumberEmail Address Promotional Code Driver 1 - Insured InformationFirst Name*Last Name*Birth Date* Date Format: MM slash DD slash YYYY Martial Status*MarriedSingleGender*MaleFemaleLicense Number*Years of Operating Experience*Relationship*ChildCo-HabitantInsuredParentSpouseOtherPast 3 yearsNumber of at fault accidents*01234 or moreNumber of not at fault accidents*01234 or moreNumber of traffic violations*01234 or moreDo you need to add a second driver?YesNoDriver 2 - Insured InformationFirst Name*Last Name*Birth Date* Date Format: MM slash DD slash YYYY Martial Status*MarriedSingleGender*MaleFemaleLicense Number*Years of Operating Experience*Relationship*ChildCo-HabitantInsuredParentSpouseOtherPast 3 yearsNumber of at fault accidents*01234 or moreNumber of not at fault accidents*01234 or moreNumber of traffic violations*01234 or more Business InformationLegal Business Name*Type of Business*CorporationLLCIndividualNon ProfitPartnershipSub ChapterOtherFEINDescription of Primary Operations*Description of Primary OperationsMailing Address* Street Address City State Zip Code Garage/Storage Address (if different than mailing) Street Address City State Zip Code Registration Address (if different than mailing) Street Address City State Zip Code Vehicle 1 - Unit InformationVehicle Type*Animal/Horse TrailerBus ConversionFifth WheelIce CabinMedium Duty Tow VehicleMotor HomePark modelTravel TrailerUtility TrailerOtherPlease specify otherModel YearMake*Model*Length (Ft)VINPersonal Mileage (Miles/Year)*Business Mileage (Miles/Year)*Current Value*Purchase Price*Purchase Date* Date Format: MM slash DD slash YYYY Describe the how the vehicle will be used for the business.*Are there any logos, signs or advertising on the unit? If yes, describe.*What percentage of operating expenses for the unit are deducted as business expenses for tax purposes.*Maximum # of Employees that travel in the unit at one time.*Are they covered by Worker's Compensation?*YesNoDo any customers ever come into the unit while parked at a business location?*YesNoPlease describe the frequency and purpose for customer in the unit AND describe the location.*Do customers ever travel in the unit?YesNoIf yes, describe.*List anyone traveling in the unit other than employees or clients.Have there been claims of any kind involving the unit in the last 3 years?YesNoDescribe the facts of the claim, include the date of loss and the amount paid.If this unit is a Mobile Clinic, do you have a current Medical Malpractice policy?YesNoList the policy limits and carrier name.Do you have a current Workers Compensation policy?YesNoIf yes, list the policy limits and carrier name.Vehicle 1 - Trip MileagePlease list how many trips you anticipate taking within the next 12 months for each of the following categories:Number of trips traveling 0-50 miles*Number of trips traveling 51-200 miles*Number of trips traveling over 200 miles* Current InsuranceInsurance CarrierCurrent PremiumExpiration Date Date Format: MM slash DD slash YYYY Coverage OptionsPlease Note: Liability Coverage will be included for all motorized vehiclesComprehensive Deductible250500100025005000otherCollision Deductible250500100025005000otherTowing/Roadside AssistanceIncludeExcludeTotal Loss ReplacementIncludeExcludeWindshield/Glass CoverageIncludeExcludeSpecial NeedsPlease include any special coverage options you require or notes regarding your request:
