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? Yes No Company Name Phone Number Email Address Promotional Code Driver 1 - Insured InformationFirst Name* Last Name* Birth Date* MM slash DD slash YYYY Martial Status*MarriedSingleGender* Male Female License Number* Years of Operating Experience* Relationship*ChildCo-HabitantInsuredParentSpouseOtherPast 3 yearsNumber of at fault accidents* 0 1 2 3 4 or more Number of not at fault accidents* 0 1 2 3 4 or more Number of traffic violations* 0 1 2 3 4 or more Do you need to add a second driver? Yes No Driver 2 - Insured InformationFirst Name* Last Name* Birth Date* MM slash DD slash YYYY Martial Status*MarriedSingleGender* Male Female License Number* Years of Operating Experience* Relationship*ChildCo-HabitantInsuredParentSpouseOtherPast 3 yearsNumber of at fault accidents* 0 1 2 3 4 or more Number of not at fault accidents* 0 1 2 3 4 or more Number of traffic violations* 0 1 2 3 4 or more Business InformationLegal Business Name* Type of Business*CorporationLLCIndividualNon ProfitPartnershipSub ChapterOtherFEIN Description of Primary Operations* Description of Primary Operations Mailing 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 other Model Year Make* Model* Length (Ft) VIN Personal Mileage (Miles/Year)* Business Mileage (Miles/Year)* Current Value* Purchase Price* Purchase Date* 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?* Yes No Do any customers ever come into the unit while parked at a business location?* Yes No Please describe the frequency and purpose for customer in the unit AND describe the location.*Do customers ever travel in the unit? Yes No If 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? Yes No Describe 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? Yes No List the policy limits and carrier name.Do you have a current Workers Compensation policy? Yes No If 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 Carrier Current Premium Expiration Date MM slash DD slash YYYY Coverage OptionsPlease Note: Liability Coverage will be included for all motorized vehiclesComprehensive Deductible250500100025005000otherCollision Deductible250500100025005000otherTowing/Roadside Assistance Include Exclude Total Loss Replacement Include Exclude Windshield/Glass Coverage Include Exclude Special NeedsPlease include any special coverage options you require or notes regarding your request:
