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Recreational Vehicle Insurance Quote Request
 
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Customer Information
First Name:  
Middle Name:  
Last Name:  
Sex:   M  F

Date of Birth:

 
Social Security Number:  
     
Phone Number:  
Home Address:  
City, State, Zip Code:  
Marital Status:  

Married   Single   Other
Email Address:  
Primary Residence:   Own Home/ Condo
    Own Mobile Home: 10 years old or newer
    Rent
    Live with Parents
    Other
     
Driving Record (prior 35 months)    

Number of/ Nature of Tickets (all vehicles)

  
Number of/ Nature of AF/ NAF Auto/ Motorcycle Accidents:  
Automobile Driver License Status:  

Motor Home/ Travel Trailer Information
Motor Homes:   Class A
    Class B
    Class C
    Bus Conversion

Travel Trailers:

   Conventional
    Pop-Up
    Fifth Wheel
    Truck Camper
Year:  
Make:  
Model:  
Rating Base (include tax, title, and license fees if TLR coverage):   $
Garaging ZIP Code:  
Anti-Theft Device:   Yes  No
Anti-Lock Brakes:   Yes  No
Vehicle Use:  

30 days
    30-150 days
   

150 days

Primary Residence- check one:

  

Traveling
    Non-Traveling
Underwriting Information
Other Policies (5% Discount)    
Automobile:  
Boat / PWC:  
Motorcycle / ATV:  
 Snowmobile:  
     
Names of Co-Owners:  
Name of Regular Operators: (Any operator with regular access to insured vehicle more than 12 times a year)  
Names of Household Resident Operators:  
Coverage Information
Physical Damage Coverage:   Total Loss Replacement (new RV's only)
    Agreed Value
    Actual Cash Value
     
Physical Damage Deductibles::   $250
    $500
    $1,000
    $2,500
     
Liability Coverage Limits (Motor Home Only):  

UM/ UIM Coverage Limits (Motor Home Only):

  
     
Medical Payments Coverage:   $1,000
    $2,500
    $5,000
    $10,000
     
Emergency Expense Coverage:  

$750 (included)
    $2,000
    $7,500
     

Vacation Liability ($10,000- $500,000):

  
     

Personal Effects Coverage ($1,000- $99,000):

  
     
Deluxe Package (Disappearing Deductibles & Scheduled Medical Benefits):   Yes  No
     
Roadside Assistance:   Yes  No
     
Full Timers Package:   $50,000/ $100,000
    $100,000/ $300,000
    $250,000/ $500,000
    $300,000 CSL
    $500,000 CSL
     
Trailer Coverage (up to $20,000; $2,500 coverage included):  
 

 
 

Haley Insurance Agency

P.O. Box 8787 - The Woodlands TX, 77387

Phone: 281-364-7888  -  Toll Free: 1-888-4 BIKERS  -  Fax: 281-367-1127

Email: info@haleyinsuranceonline.com

Webmaster: Texas Marketing Group