Hartland Insurance Brokers - Recreational Vehicle Insurance

Name:
Address:
City:
Province:
Postal Code:
Phone Number:
Email Address:
Name of Principal Operator:
Date of Birth:	Date and time
Number of child(ren) who are licensed drivers:
Child #1
Name of child:
Date of Birth:	Date and time
Number of years licensed for driver:
Child #2
Name of child:
Date of Birth:	Date and time
Number of years licensed for driver:
Any at fault accidents in the past 6 years:	YesNo
If yes, # of claims & details:
Any driving convictions in the past 3 years:	YesNo
If yes, # of tickets & details:
Value of Rec. veh.:
Number of CC's:
List Price New:
List Each Vehicle you wish to insure
Vehicle #1
Make:
Model:
Serial #:
Vehicle #2
Make:
Model:
Serial #:
Vehicle #3
Make:
Model:
Serial #:
Liability limit requested:
Coverage Preferred:
Deductible:
Can we Quote on your Home & Auto:	YesNo
If yes, when does it expire:	Date and time

Do you have Accident Forgiveness on your policy? This endorsement forgives your fist accident and your driving record stays the same.