American Risk and Insurance Associates, Inc.

Personal Insurance - Recreational Vehicle

Please take the time to fill out the following information so we can provide you with a free, no obligation insurance quote. Please provide as much information for the most accurate quote. This information is confidential and will be used for quote purposes ONLY.

You will be contacted by e-mail, fax or phone within 24 hours of submission of online questionnaire.
No coverage is bound by this submission.

Basic Information *Required information

First name*
MI
Last name*
Address *
City*
State*
Zip*
Marital Status
Best way to be contacted?*
Phone number (add area code)*
Best time to call*
Fax number
Work number
E-mail address *
Occupation
How long
Additional Comments:

Driver Information

Current Status of Driver's License
Number of Drivers?
Number of years driving a motor home
Are you currently insured?
If insured, name of insurance carrier:
Number of at-fault accidents in the last 3 years
Number of minor traffic violations in the last 3 years
Number of major traffic violations in the last 3 years
Have you completed a state approved driver safety courses
Do you have any bankruptcies, tax liens, judgments, foreclosured or repossissions?

Vehicle Information

Model Year
Description of motor home
Make
Model
Type of Use
Is your motor home equipped with audible anti-theft device?
Is the motor home co-owned?
Value of motor home
Value of personal effects	$
Is the motor home used as a primary residence at least 150 days a year?

Coverage Information

Liability Coverages
Coverage Packages
Full Coverage Options
Optional Coverages

Quotes are based on information provided, which will be verified before acceptance. Acceptance is based upon your continuing qualification. Individual savings may vary. Additional information may be required to complete accurate quote.
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