Mobile Home Owners Insurance
Quotation Form
Your Personal Data: |
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| Your Name: |
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| Property Address: |
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| City: |
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| Your "County" is? |
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| *State: |
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| Zip/Postal: |
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| E-Mail (REQUIRED): |
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| Confirm E-Mail: |
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| Phone: |
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| Fax (optional): |
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Owners Date of Birth?
(Some carriers use birthdates for additional discounts) |
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Current Home Lender & Loan Amount?
(Some carriers require for replacement values) |
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| Dwelling Information |
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| Year Home Built: |
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| Home Square footage: |
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Describe this Modular
or Mobile Home:
(Year, Make, Model) |
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Dimensions:
(Length x Width) |
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| Number of units: |
1 family
Duplex |
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| Occupancy type: |
Owner Occupied
Tenant Occupied
Seasonal
Vacant or For Sale
(Describe in remarks if
vacant or for sale.) |
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| Mobilehome Location: |
Inside City Limits
Inside Park
Inside Subdivision
(describe Park name, or
Subdivision name below,
if any.)
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| Roof type: |
Shingle
Wood Shake
Tar & Gravel
Metal
Other |
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| Is Mobilehome tied down? |
Yes
No |
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Does Mobilehome have basement or foundation?
(If yes, describe in comments.) |
Yes
No |
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| Does Mobilehome have skirting? |
Yes
No |
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| Are there handrails on steps and decks? |
Yes
No |
| Is there a trampoline on premises? |
Yes
No |
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| Do you own animals or pets? |
Yes
No |
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| If yes, list type- for Dogs, list breed: |
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| Do you have a swimming pool? |
Yes
No |
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| If yes, list description of fencing and diving board: |
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| Other structures or outbuildings on premises? |
Yes
No |
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| If yes, describe outbuildings and values: |
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| Fire Protection |
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# of feet to nearest
fire hydrant: |
# of miles to nearest
fire station: |
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| Plumbing type: |
PVC
Copper
Galvanized
Mixed (Copper/Galvanized) |
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| Circuit Breakers or fuses? |
Breakers
Fuses |
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| Heating Type (central thermostat?): |
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Fireplace or Woodburning Stove?
(If yes, describe) |
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Any business conducted on premises?
(If Yes, please describe in detail) |
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| Currently Insured? |
Yes
No |
| Current Carrier & Expiration Date: |
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Past Bankruptcies and Repossessions?
(If yes, describe in detail) |
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| Prior Claims? |
Yes
No |
| Describe claims in detail: |
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| # Bedrooms: |
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# Bathrooms: |
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| Garage or Carport? |
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# of cars,
attached or detatched? |
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Special features:
(i.e., deck, air conditioning, alarm systems, jacuzzi, screened porch, etc.) |
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| Coverages: |
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| Dwelling Cov. |
$ |
Contents |
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| Liability Cov. |
$ |
Deductible
($250, $500, $1,000, etc.) |
$ |
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Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here): |
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| Send my quotation via: |
E-Mail
Fax
Regular Mail
Call Me By Phone |
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