[Breathe – RV, Travel Trailer, Motorhome Application]

Type of Unit*
- Camper
- Travel Trailer
- Tent Trailer
- Horse Trailer
- Mobile Home
- Motorhome
Motorhome Class:*
- "A" Diesel
- "C" Diesel
- "A" Gas
- "C" Gas
Is the trailer a 5th Wheel?*
- Bumper Pull
- 5th Wheel
Does your Horse Trailer have Living Quarters?*
- Horse Trailer Only
- Horse Trailer w/ Living Quarter
Is this vehicle purchased Brand New or Used?*
- Brand New
- Used
RV / Travel Trailer / Motorhome Details

Purchase Date*
MM slash DD slash YYYY
Purchase Price*
Year*
Make*
Model / Trim level*
VIN Number*
Length*
How will the vehicle be used?*
- Pleasure Use
- Seasonal
- Residence: PERM
- Residence: TEMP
- Jobsite: PERM
- Jobsite: TEMP
Who will the unit be titled to?*
Any Anti-Theft Devices*
- None
- Alarm
- Active Disabling Device
- Passive Disabling Device
Check All That Apply
Is this unit rented to others?*
- Yes
- No
Is the unit permanently sited & skirted?*
- Permanently Sited
- Permanently Sited & Skirted
- Not permanently sited or skirted
Is your mailing address the same location the unit is stored?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Lien Holder Information

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