Welcome to Vicencia & Buckley Insurance.

Recreational Vehicles - Request for Proposal

Type of Recreational Vehicle?

Motor Home/Travel Trailer	Boat	Personal Watercraft	Motorcycle

B.	Registered Owner:

Address:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

FAX Number:

Email Address:

Website:

Garaging / Mooring Address (if different):

Address 1:

Address 2:

City:

State:

Zip:

E.	Operator Information:

Name

Date of Birth

Marital Status

Years Licensed

DL Number

Any Safety Courses

F.	Vehicle / Vessel Information:

Make / Model

Year

Cost New

Annual Mileage

Vessel Construction /Length

ID #

Vessel Engine:

Inboard	Outboard

Liability Limits:

$25,000	$50,000	$100,000	$300,000	$500,000

Have you had any RV/ vessel claims in the past three (3) years?

Yes	No

If yes:

Date of Loss	Description	Open/Closed	Amount Paid

License #: 0578496
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The information herein is for illustration purposes only and is designed as a general description of coverage's. Coverage will be determined by the actual policy language.

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