QUOTE

Motor Home Insurance Contact Form

Contact Name

Contact phone/email address

Year, make and model?

Registration?

Market Value?

Is the motor-home undergoing refurbishment/restoration?

Yes

No

If so when will it be completed? Sunday, May 20, 2012 Date selector

Approximate number of KM travelled each year?

Name & Age of the main driver?

Have you had any claims/losses within the lst 5 years?

Yes

No

If yes please provide details

Additional Comments?