Office  Hours: M-F  9am to 5pm
670 E 32nd St. Suite 12
  Yuma, AZ   85365    
Call today: (928) 317 1212

Arizona-RV and Travel Trailer Quoting Information

RV and Travel Trailer Quote Application

Please provide as much information as possible within the application below for the most accurate quotes available.
Upon completion of this information, hit "submit" once and the form will be sent to a representative for quoting. The information provided will be quoted among the multiple insurance carriers our office proudly represents. A representative will respond with the quotes via the contact option selected, normally in 1 business day or less.

Thank you for your time and we look forward to assisting you!

Applicant Information
First Name:
Last Name:
Garaging Address Street 1:
Garaging Address Street 2:
City:
State:
Zip Code: (5 digits)
Mailing Address:
Marital Status: Single
  Married


Date of Birth:
Social Security #:  (Optional)
License Status: Valid License
  *Suspended License
  Permit
  Revoked/Other
*If your license has been suspended in the past 5 years, please give details on when and for how long:
Do you need an SR-22? No
  Yes
Note any accidents, tickets or violations in the past 3 years:
Co-Applicant Information
First Name:
Last Name:
Relation to Insured:
Date of Birth:
Listed Driver:
*Yes
  No- Exclude Driver, no coverage on this policy
*Co-applicants license status:  Valid License
  *Suspended License
  Permit
  Revoked/Other
If Co-applicants license has been suspended in the past 5 years, please give details on when and for how long:
Does Co-applicant need an SR-22?  No
  Yes
Note any accidents, tickets or violations for Co-applicant:
Contact Information
Daytime/Home Phone #:
Cell Phone #:
Work Phone #:
E-mail:
Preferred method of contact: Daytime/Home

Cell phone
  Work
  E-mail
Person to contact:
Financial Information
RV/Travel Trailer
Ownership Type:
*Lienholder/Bank name:  
*Lienholder/Bank address:
*Lienholder/Bank City:
*Lienholder/Bank State:
*Zip Code:
Select type of unit: RV/Motor home
  Travel Trailer
RV/ Travel Trailer Information: Year

Make

Model
*If available, please provide for a more accurate quote. *V.I.N
Select Class of unit:  Conventional RV- Class A
  Mini-motor home- Class C
  Camper Van- Class B
  Professional conversion
  Non-professional conversion/home built
  Traditional Travel Trailer
  5th Wheel Trailer
  Utility Trailer/Toy Hauler
Stated Value of unit:
How is unit used:  Recreational Use- less than 30 days a year
  Recreational Use- 30 to 150 days a year
  Recreational Use- equal to or greater than 150 days a year
  Primary Residence- used for travel to multiple locations, has plates
  Primary Residence- non-moving, not plated (may be applicable for stationary Mobile Home policy)
Any alarm or security features?:
What type of coverage? Full Coverage
  Liability Only
REQUESTED LIMITS:
(otherwise quoted with 100/300/50 for liability, $500 deductibles for Comp. & Collision with Full Coverage):
Optional Coverages:  Uninsured Motorist
  Underinsured Motorist
  Medical Payments
  Vacation Liability
  Personal Effects (with Full Coverage)
How much value on Personal Effects?:
  Emergency Expense/Loss of use (with Full Coverage)
  Roadside Assistance (with Full Coverage)
Property Information
Property Type:
Occupancy:
How long at this address?:
Occupation/Job Title:
Highest Level of education:
Other Information
Currently Insured? No
  *Yes
*If yes, with what company?:
*For how long?:
Triple A (AAA) Member?:
Comments:
I authorize the Sheltra Insurance Group to verify
my credit and Motor Vehicle driving history.