Recreational Vehicle

Name:
Email Address:
Address:
City:
Province:
Postal Code:
Phone Number:
Name of Principal Operator:
Date of Birth:	/ / yyyy   mm   dd
Marital status:	Married Single
Name of Spouse:
Date of Birth:	/ / yyyy   mm   dd
Number of child(ren) who are licensed drivers:
Name of child #1:
Date of Birth #1:	/ / yyyy   mm   dd
Number of years licensed for driver#1:
Name of child #2:
Date of Birth #2:	/ / yyyy   mm   dd
Number of years licensed for driver#2:
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#:
Make: Model: Serial#:
Make: Model: Serial#:
Make: Model: Serial#:
Liability limit requested:	$200 000 $500 000 $1 000 000 $2 000 000
Coverage Preferred:	All perils Collision Comprehensive Specified perils
Deductible:	$100 $250 $500 $1000