Commercial Use Insurance Worksheet
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1
2COMMERCIAL USE INSURANCE WORKSHEET
THIS IS NOT AN APPLICATION!
Agent Certification
Thum Insurance Agency, L.L.C.
Producer Name: __________________________________
3140 3 Mile Rd NE
Address: _________________________________________
Grand Rapids, MI 49525-3165
800-866-0777 Fax: 616-957-1204
_________________________________________________
Contact: __________________ Agency Code: __________
Fax or email this worksheet to us for a proposal.
Phone: __________________ Fax: _____________________
This is just a worksheet to gather information for a quotation.
State: ___ County where unit is Garaged or Located: ______________ Effective Date: _________ Purchase Date: ______________
Applicant:
Phone: ______________________________
Co-Applicant:
First Name: ________________________ M.I. ___ Last Name _______________________________Phone: _____________________________
Mailing Address: ___________________________________________________City: _________________________ State:____ Zip: __________
Principal Garaging/Storage
Location: (if not same as mailing) _____________________________________________City: __________________________ State: ___ Zip: _________
Registration
Address: _____________________________________________________________City: __________________________ State: ___ Zip: _________
Driver Information
(complete for all drivers)
Marital
Social Security
# of years
Driver’s License #
Birth
Driver
Name
Sex
Status
(Valid U.S. or Canadian)
Number
RV driving
Date
#
experience
M
F
S
M
1
M
F
S
M
2
M
F
S
M
3
Violations:
Violation Type
Driver
Name
(ie. afa, speed,
Date of
Comments:
#
etc)
Violation
Vehicle Information
Year
Make
Model
Length
Vehicle ID #
Current Value
Purchase
Price
$
$
$
$
Type of Vehicle
[ ] Conventional
[ ] Mini Motor Home
[ ] Camper Van
[ ] Conventional
[ ] Fifth-Wheel
[ ] Pop-up Camper
[ ] Mounted Camper
Motor Home
(Class C)
(Class B)
Travel Trailer
Travel Trailer
(Class A)
[ ] Bus Conversion (professional)
Special Hazard [ ] Risk/Non-Professional RV Conversion
(Two Interior and Two exterior photos showing all sides of RV must be submitted.)
Loss Payee
Name, Address, City, State and Zip
1 of 2
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Parent category: Legal