- Recreational Vehicle Insurance Quote Form
Donahue-Stangle-Brown Insurance Agency, is licensed to sell insurance in the State of Ohio. If you are not a resident of the State, or if the exposure you wish to insure is not in the State, we will be unable to provide a quote. Quote indications provided by e-mail from this form are estimates only and are subject to change upon formal application and additional information obtained or revised. Please note that all information submitted will be held confidential except for submission to appropriate insurance carriers and/or representatives for the purpose of obtaining quotes. Donahue-Stangle-Brown Insurance Agency, accepts no responsibility for electronic piracy, etc., when any information is submitted electronically. Completing and submitting the following information indicates understanding and acceptance of these terms and conditions. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.
General Information
Name:
Address:
City:
   State:    ZIP: 
County:
   Email: 
Evening Phone:
 ()
Day Phone:
 ( )
Best time to call:
 am pm
Occupation:
         How long at current job: years months
Current Recreational Vehicle Insurance Company (not agency)
Company Name:
Policy Exp. Date:
Premium:
 $
Term:
 6 Months 1 Year Other 
Recreational Vehicle Information:
(include all vehicles you or your family members own or lease) 


Motor Home
Year
Make
Model
Sub Model
Body Type
Vehicle ID# (VIN)
19
Name of Title Holder
Annual Mileage
Drive to school, work, station?Yes No
# of miles (one way): 
Vehicle equipped w/ airbags?
Yes No
Anti-theft devices?
Yes No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip: 
Snow Machine #1
Year
Make
Model
Value
19
Snow Machine #2
Year
Make
Model
Value
19
Snow Machine #3
Year
Make
Model
Value
19
Boat #1
Year
Make
Model
Value
Length
Horse Power
19
InboardOutboardOutdriveJet
Boat #2
Year
Make
Model
Value
Length
Horse Power
19
InboardOutboardOutdriveJet
Boat #3
Year
Make
Model
Value
Length
Horse Power
19
InboardOutboardOutdriveJet
Driver Information:
(including all licensed drivers in your household)


Driver's Name
Occupation
Relation
to you
Date of birth
(Mo/Day/Yr)
Male/
Female

M / F
Married/
Single

M / S
Completed
# of Yrs.
Licensed
Drivers
Education
Course
Accident
Prevention
Course
Self
M
F
M
S
Y
N
Y
N
M
F
M
S
Y
N
Y
N
M
F
M
S
Y
N
Y
N
M
F
M
S
Y
N
Y
N
M
F
M
S
Y
N
Y
N
Driver History
If you answer "yes" to any of the following questions below,
please explain in the space provided:

Has any driver listed:

1. Been convicted of any moving traffic violation in the past 3 years?
Yes No
    If yes, please answer the following:


Driver
Date
Type of Conviction
Time
Fines
Speed
Over Limit
$
MPH
$
MPH
$
MPH
$
MPH
$
MPH

2. Had his/her license suspended or revoked?
    Answer only if "yes":


Driver
Suspended
Revoked
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

3. Been convicted of driving under the influence of alcohol or drugs?
    Answer only if "yes":


Driver
Alcohol
Drugs
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

4. Been involved in any accidents, regardless of fault, in the past 5 years?
Yes No
    If yes, please answer the following:


Driver
Date
Cost
Fines
Injuries
At Fault
Time
Description
$
$
Y
N
Y
N
$
$
Y
N
Y
N
$
$
Y
N
Y
N
$
$
Y
N
Y
N
$
$
Y
N
Y
N
Additional Comments:
Please give any additional comments about the coverage you desire:

Thank you for your time in submitting this Recreational Vehicle Insurance Quote Form.
One of our representatives will respond to your submission as soon as possible!



Donahue-Stangle-Brown Insurance Agency
20 N. Main St., Box 519, Frankfort, OH 45628
Phone: (740)998-5544 Fax: (740)998-4316