FAXQuote in 60 Minutes
or less... (8:30-5:30 PT)
1. Print this form 2.
Complete and fax to: 1-818-735-6778
Principal Operator ____________________________
Date of Birth___________
Street Address ____________________________________________________
City ______________________________ State ______
Zip ________________
Phone ( ______ ) _______________________
>> Will your RV be used for recreational purposes only? Yes No
>> Will you be using your RV as a full-time residence?
Yes No
>> If Travel Trailer: For permanent stationary use only?
Yes No
>> Will your RV be used in connection with business? Yes No
>> Discount: Are you a member of an RV Association?
Yes No
>> Any tickets or at-fault accidents in the last 3 years? Yes
No (Please list)
(Circle One) Motor Home
Travel Trlr Camper Van 5th
Wheel Truck Mtd Camper
Year _____ Length ______ Make/Model ________________________________
Market Value: $_______________ Original Purchase
Price: $_______________
Circle One
Deductible option you prefer: $250 $500 $1000
$2500
Motor Home Only:
Liability Limits you prefer: $100/300/50
$250/500/100 $1 Million
Name of your RV Dealer: __________________________________________
Your fax number: ( ______ ) ________________
Thank you. Fax this form to 818-735-6778 and you'll receive a quotation
by fax within 60 mintues. Call
today for an immediate quotation... 800-400-0186
x589
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