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Marketing Direct
Insurance Services Inc.
463 Brewster Ave, Suite 5
Redwood City, CA 94063
Toll Free: 800-924-5377
Phone: 650-365-1669
Fax: 650-365-1693
E-Mail us at:
office@marketing-direct.com

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© 2010 Insurance Web Sales

Lowest California Auto, Homeowners, Motorcycle and Boat Insurance Rates! FAST Phone & Online Estimates.

FREE
QUOTES!

On-Line RV & Motorhome
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!

YOUR PERSONAL DATA:

Your Name:

Street Address:

City:

State: (Must be California)

Zip/Postal:

E-Mail (REQUIRED):

Phone:

Fax (optional):

Marital Status:
Single Married
Homeowner?
Yes No

Currently Insured?
(If yes, list carrier, and # of years
continuous. If no, type NONE)

DRIVER INFORMATION #1

Name: Birthdate:

Sex: # Years U.S.
Auto License:

Driver License Number (REQUIRED by carriers to offer rate)

Number & Type of
Accidents within
last 3 years: Number & Type of
MINOR Cites within
last 3 years:

Number & Type of
MAJOR Cites within
last 3 years: Daily commute
in ONE WAY miles:

Does Driver need
an SR22 FILING? Yes No Comments or
Remarks?

DRIVER INFORMATION #2 (if none, leave blank)

Name: Birthdate:

Sex: # Years U.S.
Auto License:

Driver License Number (REQUIRED by carriers to offer rate)

Number & Type of
Accidents within
last 3 years: Number & Type of
MINOR Cites within
last 3 years:

Number & Type of
MAJOR Cites within
last 3 years: Daily commute
in ONE WAY miles:

Does Driver need
an SR22 FILING? Yes No Comments or
Remarks?

R.V. #1 INFORMATION

Year of vehicle: Make & Model:

Type (mobile/motor home, trailer, etc.): Length in Feet:

Annual Mileage: Value $:

List Special Equipment & Values
(i.e., stove, refrigerator, special features, etc.)

R.V. #1 COVERAGES:

Limits of
Liability: $25/50 BI / 15 PD
$50/100 BI / 50 PD
$100/300 BI / 50 PD

Comprehensive
& Collision: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Do you want
Medical Coverage? Yes No   Uninsured
  Motorists? Yes No

R.V. #2 INFORMATION

Year of vehicle: Make & Model:

Type (mobile/motor home, trailer, etc.): Length in Feet:

Annual Mileage: Value $:

List Special Equipment & Values
(i.e., stove, refrigerator, special features, etc.)

R.V. #2 COVERAGES:

Limits of
Liability: $25/50 BI / 15 PD
$50/100 BI / 50 PD
$100/300 BI / 50 PD

Comprehensive
& Collision: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Do you want
Medical Coverage? Yes No   Uninsured
  Motorists? Yes No

Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone

Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Recreational Vehicle Quote NOW!

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