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Step 1 of 5 - Basic Details

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Dealer Contact Name

Hidden

Dealership

Basic Details

Name(Required)

First Name Last Name

Phone(Required)

SMS receive information

This is a number that can be texted and I agree to receive information and updates via SMS text

This is a landline and/or I do not wish to receive information via SMS text

Email(Required)

Select State*(Required)

Type of Unit(Required)

DRIVER DETAILS

Date of Birth(Required)

MM slash DD slash YYYY

Gender

Male

Female

Marital Status

Married

Single

Widow

Drivers License Number(Required)

Drivers License State(Required)

Residence Address(Required)

City

Zip Code

Are you a Homeowner?

Yes

Any tickets or accidents in the last 36 months?

Yes

Do you require a SR22?

Yes

Is there a second driver?

Yes

Name

First Last

Second Driver Date of Birth

MM slash DD slash YYYY

Second Drivers License Number

Second Drivers License State

Second Driver Gender

Male

Female

Second Driver Marital Status

Married

Single

Widow

Any tickets or accidents in the last 36 months?

Yes

Do you require a SR22?

Yes

VEHICLE DETAILS

VIN

Year(Required)

Make(Required)

Model(Required)

Prior Auto Insurance Carrier

Liability Limits (BI/PD)

25/50

50/100

100/300

250/500

Liability Only

Yes

UM/UIM

Yes

Comprehensive Deductible

$250

$500

$750

$1000

Collision Deductible

$250

$500

$750

$1000

Add Additional Vehicles

VIN

Year

Make

Model

Current Insurance Carrier

BI/PD Limits requested

Liability Only

Yes

UM/UIM

Yes

Comprehensive Deductible

$250

$500

$750

$1000

Collision Deductible

$250

$500

$750

$1000

Add Additional Vehicles

VIN

Year

Make

Model

Current Insurance Carrier

BI/PD Limits requested

Liability Only

Yes

UM/UIM

Yes

Comprehensive Deductible

$250

$500

$750

$1000

Collision Deductible

$250

$500

$750

$1000

Add Additional Vehicles

VIN

Year

Make

Model

Current Insurance Carrier

BI/PD Limits requested

Liability Only

Yes

UM/UIM

Yes

Comprehensive Deductible

$250

$500

$750

$1000

Collision Deductible

$250

$500

$750

$1000

Add Additional Vehicles

VIN

Year

Make

Model

Current Insurance Carrier

BI/PD Limits requested

Liability Only

Yes

UM/UIM

Yes

Comprehensive Deductible

$250

$500

$750

$1000

Collision Deductible

$250

$500

$750

$1000

Add Additional Vehicles

VIN

Year

Make

Model

Current Insurance Carrier

BI/PD Limits requested

Liability Only

Yes

UM/UIM

Yes

Comprehensive Deductible

$250

$500

$750

$1000

Collision Deductible

$250

$500

$750

$1000

Member of USAA?

Yes

Do you have an umbrella insurance policy?

Yes

Homeowner?

Yes

Tell us why you're shopping...

Who referred you to Happy Camper Insurance?(Required)

Anything else we should know?

Vehicle Details

Specific Vehicle Type

Year

Manufacturer

Year(Required)

Manufacturer(Required)

Length

Model Name and Number(Required)

Model Name and Number

VIN

Value

Length

Value (Excluding trailer value)

Value

Engine Size in CCs

VIN

Trailer Value

Trailer Year

Trailer Make

Trailer Serial Number

Hull Type

HIN/Hull ID Number

Motor Type

Motor Year

Motor Make

Number of Motors

Total Horsepower

Maximum Speed

Primary Navigation Area

Inland- within mooring/storage state only

Coastal- up to 75 miles from mooring/storage state

Anywhere within the US

Mooring type

Private Residence

Marina

Boat Storage Facility

Other

Storage Address

City State / Province / Region

Is your vehicle used off road only?

Yes

Is your vehicle modified for enhanced performance?

Yes

Will you use this vehicle more than 180 days a year?

Yes

Will this vehicle be stored away from the home?

Yes

Is the storage address different than the residence address?

Yes

Storage Address

Storage City

Storage State

Storage Zip

Is the vehicle permanently stationary?

Yes

Stationary address

Stationary Zip

Discounts and Savings!

Homeowner

Had Boat Insurance in the Past Year

Discounts and Savings!

Member of Motorcycle Association

Had Motorcycle Insurance in the Past Year

Cycle Safety Course in the Last 3 Years

Homeowner

Has the Named Insured had Motorcycle liability insurance in the last 12 months?

Yes

Prior Motorcycle Insurance Carrier

Prior Policy Term Expiration Date

Name of motorcycle association

Date of Safety Course Completion

Member of Good Sam RV Association

Yes

Member of USAA

Yes

Had RV Insurance in the Past Year

Yes

Do you have an umbrella insurance policy?

Yes

Home Owner

Yes

Completed an RV driving or towing course in the last 12 months

Yes

Number of Slide Outs

Tell Us Why You’re Shopping

Who referred you to Happy Camper Insurance?

Name of contact at the dealership, blog, campground, etc. (if applicable)

Name of Dealership(Required)

Contact of Dealership(Required)

Anything else we should know?

Driver Details

Drivers Date Of Birth(Required)

MM slash DD slash YYYY

Drivers License Number

Drivers License State

Residence Address(Required)

Street Address City State ZIP Code

Gender

Male

Female

Marital Status

Married

Single

Widow

Any tickets or accidents in the last 36 months?

Yes

Is there a second driver?

Yes

Second Driver

Second Driver First Name Second Driver Last Name

Second Driver Date of Birth

MM slash DD slash YYYY

Second Drivers License Number

Second Driver Gender

Male

Female

Second Driver Marital Status

Married

Single

Widow

Is the second driver on the vehicle title?

Yes

Any tickets or accidents for the second driver in the last 36 months?

Yes

Does the second driver reside in the same household?

Yes

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2266 South Dobson Road
Mesa AZ 85202
844-322-6849
info@happycamperinsurance.com

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