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Request a quote for your Motor Home Insurance

Lewis Insurance Associates now offers you the ability to request a free, confidential quote online using the form below.

( * indicates required information)

GENERAL INFORMATION:
*Name:
*Address:
*City:
*State:
*Zip Code:
*E-mail address:
*Daytime Phone Number:
*Current Insurance Carrier :
*Exp. Date of Current Insurance:
DRIVER INFORMATION - Please list ALL persons of driving age in your household below:
Driver 1:	*Name:
	*Sex:	Male Female
*Marital Status:		Single Married
*Date of Birth:		Mo. Day Year
*Date First Licensed:		Mo. Year
*Social Security Number:


Driver 2:	Name:
	Sex:	Male Female
Marital Status:		Single Married
Date of Birth:		Mo. Day Year
Date First Licensed:		Mo. Year
Social Security Number:

Driver 3:	Name:
	Sex:	Male Female
Marital Status:		Single Married
Date of Birth:		Mo. Day Year
Date First Licensed:		Mo. Year
Social Security Number:

Driver 4:	Name:
	Sex:	Male Female
Marital Status:		Single Married
Date of Birth:		Mo. Day Year
Date First Licensed:		Mo. Year
Social Security Number:
MOTOR HOME INFORMATION :
*Make:			*Model:
*Year:			Anti-lock Brakes:	Yes No
*Vehicle Identification Number#			Annual Mileage:
DRIVING RECORD - List any and all accidents, claims, or comprehensive losses (glass, at fault, not at fault, hit and run) in the past 5 years:
Driver's Name:
Date of Incident:		Mo. Year
Describe Incident:
Driver's Name:
Date of Incident:		Mo. Year
Describe Incident:
Driver's Name:
Date of Incident:		Mo. Year
Describe Incident:
COVERAGES - Please select the coverages you would like on your quote:
*Bodily Injury:		$50,000/$100,000 $100,000/$300,000 $250,000/$500,000
*Property Damage:		$50,000 $100,000
*Medical Expense:		$1,000 $2,000 $5,000 $10,000
*Loss of Income:		Yes No
*Uninsured Motorist Bodily Injury:		$50,000/$100,000 $100,000/$300,000 $250,000/$500,000
*Uninsured Motorist Property Damage:		$50,000 $100,000
Rental Reimbursement:		20/$600 30/$900
Towing:		Yes No

In order to give you the most accurate quote, we will need to run a few reports. The first is a Motor Vehicle Report. The second is a Clue Report which shows prior claims. The third is an Insurance Score, which will contain credit information. In order to run these reports and obtain a quote for you we need your permission. By submitting this request for a quote you are giving us permission to obtain these reports. Any information which we have or may obtain about you or other individuals listed as policyholders on your policy will be treated confidentially. You have the right to see personal information collected about you and you have the right to correct any information which may be wrong. Upon your request the address of the reporting agency will be supplied so that you can request this information.
REMEMBER! Completion of this form constitutes a request for a quotation. It is not intended to replace or act as an actual insurance contract or binder.