H.L. Staebler Company Limited

The Best Insurance Is An Insurance Broker

Recreational Vehicle Insurance

Name:

Email Address:

Address:

City:

Province:

Postal Code:

Phone Number:

Name of Principal Operator:

Date of Birth:

	/		/
yyyy		mm		dd

Marital Status:

Name of Spouse:

Date of Birth:

	/		/
yyyy		mm		dd

Number of child(ren) who are licensed drivers:

Name of child #1:

Date of Birth #1:

	/		/
yyyy		mm		dd

Number of years licensed for driver#1:

Name of child #2:

Date of Birth #2:

	/		/
yyyy		mm		dd

Number of years licensed for driver#2:

Any at fault accidents
in the past 6 years?

Yes

Any driving convictions
in the past 3 years?

Yes

Value of Rec. veh.:

Number of CC's:

List Price New:

List each vehicle you wish to insure:

	Make:	Model:	Serial#
vehicle 1:
vehicle 2:
vehicle 3:
vehicle 4:

Liability Limit Requested:

Coverage Preferred:

Deductible:

Disclaimer:

H.L. Staebler Company Limited is not responsible for instructions not received and acknowledged by a confirmation via e-mail or phone call. By submitting this form, you acknowledge that you are the policyholder and the events described on this form are truthful. Only the person named as the insured in the policy documents can submit a claim report on this policy. All policy terms and conditions apply, subject to policy status at time of submission.