PERSONAL MOBILE HOME QUOTE 

PERSONAL INFORMATION        

        First Name                                  
        Last Name

        Date of Birth                                   
        Location Address                      
        Location City                              
        Location Zip Code                     
        Phone Number                            
        Fax Number                                
        E-Mail Address                           
        Who Referred You to Our Site? 
 

MAILING ADDRESS (OPTIONAL)

        Mailing Address (If Different from Location) 
        Mailing City                                 
        Mailing State                              
        Mailing Zip Code                        
 

MOBILE HOME INFORMATION

        Year                                       
        Make                                     
        Model                                    

        Length  

        Width                                
        Serial Number  

        Purchase Price

        Purchase Date                                     

COVERAGE INFORMATION              

        Dwelling Coverage

        Other Structures (10% of dwelling coverage included)

        Personal Property (50% of dwelling coverage included)

        Additional Living (20% of dwelling coverage included)

- 300,000 500,000                                                          Liability

- 1,000 2,000 3,000 4,000 5,000                                                             Medical

- 250 500 1,000 2,500 5,000 10,000                                                           Deductible

- Yes No                                                               Do you want earthquake coverage?

UNDERWRITING INFORMATION

- Yes No                                                               Is the home located in a park?

        Park name

        Park address (street, city, state, zip, lot number)

- Yes No                                                               Is the home located inside incorporated city limits?

- No Factory Installed Commercially Installed Self-Installed                                   Does the home have a wood stove or fireplace?

- Yes No                                                               Is the home tied down?

        What is the value of the home (excluding land)?

- Yes No                                                               Do you own the land where the home is located?

- Multi-sectional Mobile Home Manufactured Home Modular Home                           What type of home is this?

- Yes No                                                               Does the home have an addition exceeding 400 sq. ft.?

- Yes No                                                               Is 'Other Structure' limit higher than package limit?

        If so, what limit?

- Yes No                                                               Has your policy ever been cancelled/declined/non-renewed?

        If so, for what reason?

- Yes No                                                               Has your policy lapsed in coverage for more than 30 days?

        If so, for what reason?

- Yes No                                                               Have you had any claims in the last five (5) years?

        If so, please provide date, description and payout

- Yes No                                                               Is your home raised more than four feet on poles or blocks?

- Yes No                                                               Does the home have any non-professional built additions?

- Yes No                                                               Is there any other structure on the property over 1200 sq. ft.?

- Yes No                                                               Are there any animals with a previous biting history?

- Yes No                                                               Is there any business conducted on the premises?

MISCELLANEOUS INFORMATION

        Current Insurance Company   
        Expiration Date                           
        Current Premium                        

- No current insurance Less than one year 1 year 2 years 3 years 4 years 5 years or more                                      Continuously Insured               

Questions or Comments to help the Agent:

               

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Thank you for your interest.