Mobile Home Quote

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

Name
Street Address
City
State
Zip Code
Phone Number
Alternate Telephone
Fax Number
Email Address
Age of oldest owner
Property Information
Property Street Address
City
State
Zip Code
Purpose of Use
If commercial, how is it used?
What is the mobilehome park's name? (if on private property, please indicate)
What is the number of spaces in the park?
What year was it built?
What is the serial number?
What is the mobilehome manufacturer name?
What is the current loan amount?
Is the mobilehome tied down?
Is the mobilehome fully skirted?
Is it located within city limits?
Does the mobilehome park have a full-time resident manager?
Is it located on private property?(not in a park)
Have you ever been refused insurance in the last 3 years?
Is it located in a landslide Area?
How many stories?
If two stories, what is the ground floor square footage?
What is the total square footage of the dwelling?
Length and width of mobilehome
What is the construction type?
If structure is located in a flood zone, what is the distance to body of water?
What type of roof covering?
Was the roof updated?
If yes, what year?
What is the distance to fire protection?
Is the building in the brush?
Is there a brush hazard within one mile of the building?
If yes, has the brush been cleared by 250 feet from all sides of the building?
Is there a smoke alarm?
Is there a fire extinguisher?
Are there deadbolts?
Is the electrical updated?
Are there circuit breakers?
Does the electrical circuit box have copper wiring?
How old is the heating/ air conditioning?
Is the heating / air conditioning thermostatically controlled?
What is the energy source?
What is the heating system?
What is the cooling system?
Has the plumbing been updated?
Is the plumbing copper?
Does the mobilehome have a woodstove?
Does the mobilehome have a fireplace?
Does it have interior automatic fire sprinklers?
Is there a theft alarm?
Is there a fire alarm?
What is the earthquake zone?
Has it been earthquake retroffited?
Are there dogs on the property?
If yes, how many and what is the breed of each dog?
Are there any other pets or animals on the property?
If yes, how many and what is the description of each?
Current Coverage Information
Current Insurance Company
Expiration Date
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Desired Coverage Information
Dwelling Amount - Coverage A
Other Structures - Coverage B
Business Property - Coverage C
Loss of Use - Coverage D
Premise Liability - Coverage E
Policy Deductible
If earthquake insurance is requested, select deductible percentage %
Do you want building replacement cost coverage?
Do you want contents replacement cost coverage?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

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