Petruzelo Insurance Agency, Inc.

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	Motor Homes & Recreational Quote

Note: Required fields are marked with an asterisk (*)

Personal Information Name*:
Current Address*:
City*:
State*:
Zip*:

Home Phone*: - -

Work Phone: - -
E-mail*:

Date of Birth*:

Present Auto Insurance Company:
Date Auto Insurance Expires:
Do you own or rent your home?:
How long at your present address*:

Prior Address*:
Prior City*:
Prior State*:
Prior Zip*:

Prior Address:
Prior City:
Prior State*:
Prior Zip:

How Did You Hear About Our Agency?:

Who*:

Other*:

Driver Information Driver Name:
Driver License #:
Social Security #: - -
Date of Birth:
Gender:
Marital Status:
Occupation:
Education Level:
Number of Tickets in the Last 5 Years:

Explanation of Tickets:
Number of Accidents/Violations in the Last 5 Years:

Explanation of Accidents/Violations:

Motor Home / Travel Trailer Information Motor Home:
Travel Trailer:
Type: Conventional
Pop-Up
Fifth Wheel
Truck Camper
Year:
Make:
Model:
Length:
Width:
Garaging Zip Code:
Vehicle Use

>30 days
30-150 days
<150 days
Primary Residence - Traveling
Primary Residence - Non-Traveling

Underwriting Information Physical Damage Coverage
Total Loss Replacement (RVs up to 2 model years old)
Agreed Value
Actual Cash Value
Physical Damage Deductibles
$250
$500
$1,000
$2,500
Medical Payments Coverage
$1,000
$2,500
$5,000
$10,000
Emergency Expense Coverage
$750 (included)
$2,000
$7,500 (Full Timer's Only)
Vacation Liability
($10,000 - $500,000):

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

Deluxe Package
(Disappearing Deductibles & Scheduled Medical Benefits):

Roadside Assistance:

Liability Coverage Limits (Motor Home Only)
$50,000/$100,000
$250,000/$500,000
$300,000 CSL
$500,000 CSL

UM/UIM Coverage Limits (Motor Home Only):

Full Timers Package:
Trailer Coverage (up to $20,000; $2,500 coverage included):

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The submission of this form does not obligate you to purchase. This is for quoting purposes only and in no way provides, effects, or binds any insurance coverage.

We are licensed in the following states/provinces:
Connecticut, Maine, Massachusetts, New Hampshire, New York, Pennsylvania, Rhode Island, and Vermont

© 2009 Petruzelo Insurance Agency.   All rights reserved.
4 Research Parkway  | PO Box 5050  |  Wallingford, CT 06492-7550
Call Us Toll Free: 1-866-479-3327 | Fax: 203-269-7588
insure@petruzelo.com

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