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MOBILEHOME INSURANCE QUOTE REQUEST
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Complete the following
information if you would like to obtain a quote on Mobilehome Insurance.
Please understand this is not an application for insurance. 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. |
The home must be a single family mobilhome owner,
tenant or seasonal occupied. The mobilhome may be located on
private property or in a mobilehome park. Please complete this
Mobilehome Quote Request Form to receive an insurance proposal.
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| Personal Information |
| What is your name? |
Last
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First
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Middle
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| What is your mailing
address? |
Street
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City
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State
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Zip
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| What is your telephone
number? |
Home
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Work
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| What is your fax number? |
Fax
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| What is your email address? |
Email
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| What is the age of the oldest owner? |
Age of Oldest Owner
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| Property Information |
| What is
the property address? |
Street
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City
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State
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Zip
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| What is the purpose
of use? |
Purpose of Use
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| If commercial, how is
it used? |
Usage
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| What is the mobilehome
park's name? (if on private property, please indicate) |
Mobilehome Park
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| What is the number of
spaces in the park? |
Number of Spaces
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| What year was it built? |
Year Built
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| What is the serial number? |
Serial Number
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| What is the mobilehome manufacturer
name? |
Mobilehome Manufacturer
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| What is the current loan amount? |
Current Loan Amount
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| Is the mobilehome tied down? |
Tied Down
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Yes
No |
| Is the mobilehome fully skirted? |
Skirted
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Yes
No |
| Is it located within city limits? |
Located Within City Limits
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Yes
No |
| Does the mobilehome park have a
full-time resident manager? |
Resident Manager
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Yes
No |
| Is it located on private property?(not
in a park) |
On Private Property
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Yes
No |
| Have you ever been refused insurance
in the last 3 years? |
Refused Insurance in Last 3 Years
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Yes
No |
| Is it located in a landslide Area? |
Landslide Area
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Yes
No |
| How many stories? |
Stories
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| If two stories, what is the ground
floor square footage? |
Ground Floor Square Footage
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| What is the total square footage
of the dwelling? |
Total Square Footage
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| Length and width of mobilehome |
Length and Width (eg: 24x60)
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| What is the construction type? |
Construction Type
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| If structure is located in a flood
zone, what is the distance to body of water? |
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| What type roof covering? |
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| Was the roof updated? |
Updated Roof
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Yes
No |
| If yes, what year? |
Year Roof Updated
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What is the distance of fire protection?
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| Is the building in the brush? |
Brush
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Yes
No |
| Is there a brush hazard within
one mile of the building? |
Brush Within 1 Mile
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Yes
No |
| If yes, has the brush been cleared
by 250 feet from all sides of the building? |
Brush Cleared by 250 Feet
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Yes
No |
| Is there a smoke alarm? |
Smoke Alarm
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Yes
No |
| Is there a fire extinguisher? |
Fire Extinguisher
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Yes
No |
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Deadbolts
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Yes
No |
| Is the electrical updated? |
Electrical Update
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| Are there circuit breakers? |
Circuit Breakers
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Yes
No |
| Does the electrical circuit box
have copper wiring? |
Copper Wiring
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Yes
No |
| How old is the heating/ air conditioning? |
Age Heating/ Air Conditioning
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| Is the heating/ air conditioning
thermostatically controlled? |
Thermostatically Controlled
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Yes
No |
| What is the energy source? |
Energy Source
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| What is the heating system? |
Heating System
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| What is the cooling system? |
Cooling System
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| Has the plumbing been updated? |
Plumbing Updated
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Yes
No |
| Is the plumbing copper? |
Copper
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Yes
No |
| Does the mobilehome have a woodstove? |
Woodstove
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Yes
No |
| Does the mobilehome have a fireplace? |
Fireplace
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Yes
No |
| Does it have interior automatic
fire sprinklers? |
Fire Sprinklers
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Yes
No |
| Is there a theft alarm? |
Theft Alarm
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Yes
No |
| Is there a fire alarm? |
Fire Alarm
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Yes
No |
| What is the earthquake zone? |
Earthquake Zone
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| Has it been earthquake retrofitted? |
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| What is the fire district? |
Fire District
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| Are there dogs on the property? |
Dogs on Property
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Yes
No |
| If yes, how many and what is the
breed of each dog? |
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| Are there any other pets or animals
on the property? |
Pets or Animals
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Yes
No |
| If yes, how many and
what is the description of each? |
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| Current Coverage Information |
| What is the current insurance company? |
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| What is the expiration date of
current policy? |
Expiration Date
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| Where there any losses or claims
in the last 5 years? |
Losses - Claims
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Yes
No |
| If yes, what is the date, amount
paid and description of each loss or claim? |
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| Desired Coverage Information |
| Dwelling Amount |
Coverage A
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| Other Structures |
Coverage B
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| Business Property |
Coverage C
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| Loss of Use |
Coverage D
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| Premise Liability |
Coverage E
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| Policy Deductible |
Amount
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| If earthquake insurance is requested,
select deductible percentage % |
Earthquake Deductible
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| Do you want building replacement
cost coverage? |
Building Replacement Cost Coverage
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Yes
No |
| Do you want contents replacement
cost coverate? |
Contents Replacement Cost Coverage
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Yes
No |
| Questions or Comments |
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| Best Time to Contact You
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| Please let us know the best time to call and discuss your quote.
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Morning
Afternoon
Evening
Anytime
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Or specify other:
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