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Recreational Vehicle Insurance
Name:
Address:
City:
Province:
Postal Code:
(X1Y 2Z3)
Phone Number:
(123-456-7890)
Email Address:
(xxx@yyyy.zzz)
Name of Principal Operator:
Date of Birth:
(dd/mm/yyyy)
Marital status:
Married
Single
Name of Spouse:
Date of Birth:
(dd/mm/yyyy)
Number of child(ren) who are licensed drivers:
#1
#2
Name of child:
Date of Birth:
(dd/mm/yyyy)
(dd/mm/yyyy)
Number of years licensed
for driver:
Any at fault accidents in the past 6 years?
Yes
No
Any driving convictions in the past 3 years?
Yes
No
Value of Rec. veh.:
Number of CC's:
List Price New:
List each vehicle you wish to insure:
Make
Model
Serial#
#1:
#2:
#3:
Liability limit requested:
$1,000,000
$2,000,000
$5,000,000
Coverage Preferred:
All perils
Collision
Comprehensive
Specified perils
Deductible:
$100
$250
$500
$1000
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