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Florida Alliance



 
Recreational Vehicle/Travel Trailer Insurance Quote

We would like to provide you with a free, no-obligation recreational vehicle/travel trailer insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

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Personal Information
Name:
Address:
City:   State:   Zip:
Day Phone:   Night Phone:
Best Time To Call:   AM   PM
Email Address:

Current RV/Travel Trailer Insurance Information
Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
Term: 6 Months   1 Year   Other:

Vehicle Information
Vehicle
#1
Vehicle to be covered is a:    Recreational Vehicle (RV)     Travel Trailer
Year
Make
Model
Type
Multi-Owner
Rating Base
(Current Value)
Annual Milage
Vehicle Use
Y N
AntiTheft
Full-Timers
Liability
Options*
Roadside
Assistance/
Towing
Physical Damage Option
Y N
Y N
Y N
Collision
Comprehensive
Emergency
Expenses**
Vacation Liability***
Y N
Y N
Y N
Y N
Please complete the section below for RV (Recreational Vehicle) coverage ONLY!
(PIP) Personal Injury
Protection Coverage****
(BIPD)Bodily Injury and
Property Damage Coverage
(UM) Uninsure Motorist /
(UIM) Underinsured Motorist
Y N
Y N
Y N
Does Primary Insured have Medical/Disability Coverage?
  *  Available when Vehicle is Used as a Primary Residence
  **  Covers Temporary Living Expense Cost to Move RV/Travel Trailer
  ***  Covers BI/PD Liability when Vehicle is used as a residence on Vacation
 ****  If Primary Insured already has medical/disability coverage, they may be eligible for a discount on PIP Coverage
Y N

Vehicle
#2
Vehicle to be covered is a:    Recreational Vehicle (RV)     Travel Trailer
Year
Make
Model
Type
Multi-Owner
Rating Base
(Current Value)
Annual Milage
Vehicle Use
Y N
AntiTheft
Full-Timers
Liability
Options*
Roadside
Assistance/
Towing
Physical Damage Option
Y N
Y N
Y N
Collision
Comprehensive
Emergency
Expenses**
Vacation Liability***
Y N
Y N
Y N
Y N
Please complete the section below for RV (Recreational Vehicle) coverage ONLY!
(PIP) Personal Injury
Protection Coverage****
(BIPD)Bodily Injury and
Property Damage Coverage
(UM) Uninsure Motorist /
(UIM) Underinsured Motorist
Y N
Y N
Y N
Does Primary Insured have Medical/Disability Coverage?
  *  Available when Vehicle is Used as a Primary Residence
  **  Covers Temporary Living Expense Cost to Move RV/Travel Trailer
  ***  Covers BI/PD Liability when Vehicle is used as a residence on Vacation
 ****  If Primary Insured already has medical/disability coverage, they may be eligible for a discount on PIP Coverage
Y N

Driver Information
(include all licensed drivers in your household)
Driver
#1
Driver's Name
Drivers License Information
DL#: State: Yrs Licensed:
Relation
Date of Birth
Sex
Marital
Status
Soc. Sec. #
Courses Completed Last 3 yrs
 M
 F
 M
 S
Drivers Ed: N
Accident Prevention: N

Driver
#2
Driver's Name
Drivers License Information
DL#: State: Yrs Licensed:
Relation
Date of Birth
Sex
Marital
Status
Soc. Sec. #
Courses Completed Last 3 yrs
 M
 F
 M
 S
Drivers Ed: N
Accident Prevention: N

Driver History
Please list ANY convictions for ANY driver convicted of moving traffic violations in past 3 years
Driver
Date
Type of Conviction
Fines
Speed Over Limit
$
mph
$
mph

Please list ANY driver who has had license suspensions, revocations or DUI convictions below
Driver
License Suspended or Revoked
DUI Conviction For:
Suspended   Revoked  
Alcohol   Drugs  
Suspended   Revoked  
Alcohol   Drugs  

Please list ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver
Date
Description
Cost
Fines
Injuries
At Fault
$
$
Yes
Yes
$
$
Yes
Yes

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough fields above, such as additional
drivers, vehicles, driver histories, etc..., please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   


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