RV Insurance Binder Request Form Renter Name

RV Insurance Binder Request Form Renter Name _______________________________________________ Date __________________________ Your insured customer, _______________________________ (“Renter”), is in the process of renting an RV from _______________________________ (“RV Owner”), for the following dates _______________________________. Your customer has chosen to have his/her personal vehicle insurance as PRIMARY insurance for the period of this rental. To accommodate this request, a Binder is required. The Binder or Endorsement must cover the vehicle (“Rented RV”) and must list the name the RV Owner as an Additional Insured. To meet our requirements, the insurance must include PRIMARY COMPREHENSIVE AND COLLISION COVERAGE as well as PRIMARY LIABILITY COVERAGE. The Renter understands this promise of primary insurance coverage may amend the terms of his/her policy. The policy must cover up to the actual cash value of the rented RV. The estimated value of the RV your insured customer will be renting is $_______________. The limits of liability coverage must be at least the minimum limits as required by any applicable compulsory or financial responsibility law. The loss payee should be listed as ___________________________________ (RV Owner). No collision or comprehensive deductibles shall exceed $500.00. Manufacturer, Make and Model ______________________________________________________________ Gross Vehicle Weight __________________________ Towable

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Drivable

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Length of Unit ___________________________ feet VIN # ____________________________________________________________________________________ License Plate # ____________________________________ State __________________________________ RV Owner Name __________________________________________________________________________ Address _________________________________________________________________________________ City ____________________________________________ State ______________ Zip __________________ Below to Be Completed By Insurance Agent: Insurance Binder Effective from _____/_____/_____ 12:01 AM through _____/_____/_____ 11:59 PM Insurance Agent Representative _____________________________________________________________ Insurance Agency & Phone _________________________________________________________________ Please EMAIL this form & the Binder of Endorsement ASAP to:___________________________________

Thank you in advance for your prompt attention to this matter! August 2017