DG&M Insurance Agency Inc. : Recreational Vehicle Insurance Quote Request

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Insurance is our business. Service is our Policy.

General Information

First Name:
Middle Initial:
Last Name:
Address:
City:
State:	ZIP:
Phone:	Fax:
E-mail:

Driver Information

	Driver 1	Driver 2	Driver 3
First Name:
Middle Name:
Last Name:

NY Drivers License #:
Date of Birth: (mm/dd/yyyy):
Gender:
Marital Status:

Please check any Violations for each driver in the last three years:	None Speeding(less than 15 mph over limit) Speeding(more than 15 mph over limit) Stop sign Traffic Light DUI/DWI Reckless Driving Eluding Police Homicide with vehicle Drag Racing Suspension Other	None Speeding(less than 15 mph over limit) Speeding(more than 15 mph over limit) Stop sign Traffic Light DUI/DWI Reckless Driving Eluding Police Homicide with vehicle Drag Racing Suspension Other	None Speeding(less than 15 mph over limit) Speeding(more than 15 mph over limit) Stop sign Traffic Light DUI/DWI Reckless Driving Eluding Police Homicide with vehicle Drag Racing Suspension Other

Please check any Accidents for each driver in the last three years:	None At fault accident Not at fault accident Hit and Run Other	None At fault accident Not at fault accident Hit and Run Other	None At fault accident Not at fault accident Hit and Run Other

Please check all that apply:	None Completed approved Boater Safety Course Completed approved Motorcycle Safety Course Member of approved Motorcycle Association Other	None Completed approved Boater Safety Course Completed approved Motorcycle Safety Course Member of approved Motorcycle Association Other	None Completed approved Boater Safety Course Completed approved Motorcycle Safety Course Member of approved Motorcycle Association Other

Vehicle Information

	Vehicle 1	Vehicle 2	Vehicle 3
Type:
Vehicle Year:
Vehicle Make:
Vehicle Model:
VIN: (Optional)

Please check all that apply:	None Loran Radio Other	None Loran Radio Other	None Loran Radio Other

Boat-specific Information

	Boat 1	Boat 2	Boat 3
Boat: Value of Hull:	$	$	$
Boat: Value of Contents:	$	$	$
Boat: Value of Fishing Equipment:	$	$	$

For more information on our recreational vehicle products and companies, please contact:
Erin Schumaker or
Tessa Hewitt