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CA 0G67810 & CA 0D71028

For quick action Quote Online, Call 619-565-8703 or
Email us at clientservice@bikernet-insurance.com

QUOTE REQUEST FOR RV INSURANCE

Confidential Application

Bikernet Insurance Center LLC

First Name:

Middle Initial:

Last Name:

Phone #:

E-Mail Address:

Date of Birth:

Address:

City:

State:

Zip:

RV Association Membership?

Yes

No

Name of RV Association:

Membership Number:

Name of Vehicle Registration:

Additional Owners Named on Registration?

Yes

No

Name of Additional Owners:

Registration Address:

Years RV Experience:

Operator has taken Driver Safety Course?

Yes

No

Date:

Accidents and Violations:

Number in past 3 years:

Number at fault in past 3 years:

RV Unit Type:

Manufacturer:

Describe your RV:

Model:

Length:

VIN #:

Usage (Personal Vacations/Full-Time Home/Business)

Year of the RV:

Purchase Date:

Purchase Price:

Storage: Inside/Outside and Address of Storage and Garaging Location:

Photo: Email/attach photo to:
clientservice@bikernet-insurance.com

Additional Interests:

Yes

No

Name of Additional Interest Holder(s):

Would you like us to quote?

"Full Timer" coverage:

Yes

No

Personal Property coverage:

Yes

No

Replacement Cost Coverage:

Yes

No

Vacation Liability:

Yes

No

Emergency Expenses:

Yes

No

Medical Benefits:

Yes

No

Please Note: This is an "estimate of premium" request. No insurance coverage is granted by completing this form or by submitting it to the Company. Once you submit this estimated quote request form, we will review the information and contact you to discuss the various insurance options available to you. Thank you.

© 5 Ball, Inc.1996 - 2012. All Rights Reserved.
Bandit's Bikernet is a registered trademark of 5 Ball, Inc.
All Rights Reserved This material may not be published, broadcast, rewritten, or redistributed.

200 Broad Ave, Wilmington, CA 90744
E-Mail Bandit | Phone: (310) 830-0630
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