Legacy Wealth Management Group, Fiduciary, Investment Management, RIA, Lynchburg, Virginia, Educational Seminar, Riskalyze, Independent Financial Advisor - Motor Home Insurance : Quote Request

Legacy Wealth Management Group, Inc. (LWMG) is an SEC registered investment adviser located in Lynchburg, VA. LWMG and its representatives are in compliance with the current filing requirements imposed upon SEC registered investment advisers by those states in which LWMG maintains clients. LWMG may only transact business in those states in which it is registered or qualifies for an exemption or exclusion from registration requirements. LWMG’s web site is limited to the dissemination of general information pertaining to its advisory services, together with access to additional investment-related information, publications, and links. Accordingly, the publication of LWMG’s web site on the Internet should not be construed by any consumer and/or prospective client as LWMG’s solicitation to effect, or attempt to effect transactions in securities, or the rendering of personalized investment advice for compensation, over the Internet. Any subsequent, direct communication by LWMG with a prospective client shall be conducted by a representative that is either registered or qualifies for an exemption or exclusion from registration in the state where the prospective client resides. For information pertaining to the registration status of LWMG, please contact the SEC or the state securities regulators for those states in which LWMG maintains a notice filing. A copy of LWMG’s current written disclosure statement discussing LWMG’s business operations, services, and fees is available from LWMG upon written request or at https://adviserinfo.sec.gov/firm/brochure/322235 (LWMG’s CRD# is 322235). This information can also be found on the FORM CRS. LWMG. LWMG does not make any representations or warranties as to the accuracy, timeliness, suitability, completeness, or relevance of any information prepared by any unaffiliated third party, whether linked to LWMG web site or incorporated herein, and takes no responsibility, therefore. All such information is provided solely for convenience purposes only and all users thereof should be guided accordingly.


» Name:
» Address:
» City:
» State:
» Zip Code:
Work Phone:
» Home Phone:
Email Address:

Driver #1 Information
Name:
Age:
Marital Status:
List all citations received in the past 3 years (Please include non-moving violations).
List all accidents that were your fault.
List all accidents that were NOT your fault.

Driver #2 Information
Name:
Age:
Marital Status:
List all citations received in the past 3 years (Please include non-moving violations).
List all accidents that were your fault.
List all accidents that were NOT your fault.

Motor Home Information
Year:
Make:
Model:
Vehicle ID Number:
Body Style:
How is Vehicle Primarily Used?
Is the Motor Home Used Full Time?
List Club Affiliations, Good Sam, etc.

Select Coverage and Limits Below
	Liability
Liability Limits:
	Un(der)insured Motorist - Will Match Liability Selection
	Medical/Personal Injury Protection - Will Match Liability Selection
	Comprehensive
Comprehensive Deductible:
	Collision
Collision Deductible:
	Towing - Company Will Provide Limits
	Rental Reimbursement - Company Will Provide Limits
Please use the space below to add comments regarding any special circumstances or coverage needs.