Insurance Binder / Endorsement Request Form

Date:

Your insured, are currently planning on renting a motor home from WI-RVRentals.com, LLC. They have chosen to have their personal insurance as primary insurance for the period of this rental. The binder or endorsement should cover the vehicle and name our dealership as an additional insured. In order to satisfy our requirements, the insurance provided will be full coverage to include comprehensive, collision and liability on a primary basis. The appropriate coverage should be the actual cash value. The estimated value of the motor home he/she/they will be renting is $ 75,000. The limits of liability shall be at least the minimum limits as required by any applicable compulsory or financial responsibility law. The loss payee should be listed as Robin Richter. Any deductibles shall not exceed $500.00.

The insurance is to be effective from 12:01 AM through 12:00 PM.

a. Manufacturer: Four Winds
b. Model: Five Thousand 28A
c. Year Built: 2007
d. Length: 28 feet
e. Vehicle Identification Number (VIN): 1GBJG31U161266430
f. License Number: 5XCG228
g. Gross Vehicle Weight (GVW):12,300 lbs

Please FAX a Binder or Endorsement ASAP to 949-888-7831.

I thank you in advance for your prompt attention to this matter. Please sign and fax back this request form with binder or endorsement. Should you have any questions, please give us a call.

Agent / Representative

Agency / Insurance Company