Motor Home Quote

Marital Status *

Divorced

Divorced With Child

Married

Separated

Single

Widowed

Does the applicant have another personal lines or life policy with Farmers Insurance Group® or Farmers New World Life, including Foremost®, Bristol West®, or Toggle® Insurance? *

Yes

A life policy must be a term, whole, universal, or variable policy, have a face amount of $50,000 or greater, be issued to an adult, and be in force.

Does the primary applicant have a qualifying life policy with a minimum value of $50,000 covering an adult? *

Yes

Has the primary applicant had ANY losses in the past 3 years? *

Yes

Is the mailing address the same as the location address? *

Yes

Is the motor home registered in the name of a business? *

Yes

Has the applicant had continuous insurance or a lapse of less than or equal to 31 days? *

Yes

Operator Information: List all licensed household members & regular use operators

Operator 1 (Named Insured)

Driver 1 - Gender: *

Female

Male

Spouse is required to be listed as operator and may be excluded if requested.

Is Driver 1 Member of any association? *

Yes

Driver 1 - License Status *

Driver 1 - License Type *

How many years of experience has driver 1 had operating a Motor Home? *

Is a financial responsibility filing (SR-22) required for driver 1? *

Yes

Has driver 1 completed safety course in last 3 years? *

Yes

Any other operators? *

Yes

Driver 2 - Gender *

Male

Female

Driver 2 - Marital Status *

Driver 2 - Relationship to insured *

Spouse

Child

Other - Specify:

Is driver 2 a member of any association? *

Yes

Driver 2 Accidents or violations in the last 3 years? *

Yes

Has Driver 2 completed safety course in last 3 years? *

Yes

Is a financial responsibility filing (SR-22) required for driver 2? *

Yes

Use: *

Full-Timer

Pleasure

Other

Does the Motor Home have safety equipment? *

Airbag & Anti-Lock Breaks

Airbag(s)

Anit-Lock Breaks

None

Is there any unrepaired damage to the Motor Home? *

Yes

Location Type: *

Condition: *

Pristine

Excellent

Good

Fair

Full-Timer/Personal Liability: *

Provides comprehensive personal liability coverage similar to a homeowners policy. Includes medical payments to others and first aid expenses.

Towing/Roadside Assist: *

Provides 24-hour benefits, 365 days a year, if you get a flat tire, run out of gas, or need a battery jump. Covers towing costs incurred if the unit is disabled. Also pays for labor performed at the place of disablement for fuel delivery and vehicle lockout.

Vacation Liability: *

Provides coverage for claims made against the insured for bodily injury or property damage that results from an accident at the site where the unit is parked and being used as a dwelling or for recreational purposes.

Emergency Expense: *

Coverage for temporary housing, travel expenses, and costs to return the travel trailer to the insured's home or storage place when a covered loss occurs while more then 50 miles from home.

Scheduled Medical BFTS: *

Provides benefits to an insured for certain accidental injuries sustained while the unit is parked and being used as a dwelling or for recreational purposes.

Adjacent Structures Limit:

Coverage for structures not attached to the unit. Examples include sheds and RV ports.

Any Additional Questions or Comments? If there is more than 1 Unit, please provide responses for all of the Unit Information questions for each additional unit in this box.

Agency Information

Applicant Information

Operator Information: List all licensed household members & regular use operators

Operator 1 (Named Insured)

Unit Information