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MOBILEHOME INSURANCE QUOTE REQUEST
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.
Personal Information
What is your name?
Last
First
Middle
What is your mailing address?
Street
City
State
Zip
What is your telephone number?
Home
Work
What is your fax number?
Fax
What is your email address?
Email
What is the age of the oldest owner?
Age of Oldest Owner
Property Information
What is the property address?
Street
City
State
Zip
What is the purpose of use?
Purpose of Use
If commercial, how is it used?
Usage
What is the mobilehome park's name? (if on private property, please indicate)
Mobilehome Park
What is the number of spaces in the park?
Number of Spaces
What year was it built?
Year Built
What is the serial number?
Serial Number
What is the mobilehome manufacturer name?
Mobilehome Manufacturer
What is the current loan amount?
Current Loan Amount
Is the mobilehome tied down?
Tied Down
Yes No
Is the mobilehome fully skirted?
Skirted
Yes No
Is it located within city limits?
Located Within City Limits
Yes No
Does the mobilehome park have a full-time resident manager?
Resident Manager
Yes No
Is it located on private property?(not in a park)
On Private Property
Yes No
Have you ever been refused insurance in the last 3 years?
Refused Insurance in Last 3 Years
Yes No
Is it located in a landslide Area?
Landslide Area
Yes No
How many stories?
Stories
If two stories, what is the ground floor square footage?
Ground Floor Square Footage
What is the total square footage of the dwelling?
Total Square Footage
Length and width of mobilehome
Length and Width (eg: 24x60)
What is the construction type?
Construction Type
If structure is located in a flood zone, what is the distance to body of water?
What type roof covering?
Was the roof updated?
Updated Roof
Yes No
If yes, what year?
Year Roof Updated

What is the distance of fire protection?


Is the building in the brush?
Brush
Yes No
Is there a brush hazard within one mile of the building?
Brush Within 1 Mile
Yes No
If yes, has the brush been cleared by 250 feet from all sides of the building?
Brush Cleared by 250 Feet
Yes No
Is there a smoke alarm?
Smoke Alarm
Yes No
Is there a fire extinguisher?
Fire Extinguisher
Yes No
Are there deadbolts?
Deadbolts
Yes No
Is the electrical updated?
Electrical Update
Are there circuit breakers?
Circuit Breakers
Yes No
Does the electrical circuit box have copper wiring?
Copper Wiring
Yes No
How old is the heating/ air conditioning?
Age Heating/ Air Conditioning
Is the heating/ air conditioning thermostatically controlled?
Thermostatically Controlled
Yes No
What is the energy source?
Energy Source
What is the heating system?
Heating System
What is the cooling system?
Cooling System
Has the plumbing been updated?
Plumbing Updated
Yes No
Is the plumbing copper?
Copper
Yes No
Does the mobilehome have a woodstove?
Woodstove
Yes No
Does the mobilehome have a fireplace?
Fireplace
Yes No
Does it have interior automatic fire sprinklers?
Fire Sprinklers
Yes No
Is there a theft alarm?
Theft Alarm
Yes No
Is there a fire alarm?
Fire Alarm
Yes No
What is the earthquake zone?
Earthquake Zone
Has it been earthquake retrofitted?
What is the fire district?
Fire District
Are there dogs on the property?
Dogs on Property
Yes No
If yes, how many and what is the breed of each dog?
Are there any other pets or animals on the property?
Pets or Animals
Yes No
If yes, how many and what is the description of each?
Current Coverage Information
What is the current insurance company?
What is the expiration date of current policy?
Expiration Date
.
Where there any losses or claims in the last 5 years?
Losses - Claims
Yes No
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
Amount
If earthquake insurance is requested, select deductible percentage %
Earthquake Deductible
Do you want building replacement cost coverage?
Building Replacement Cost Coverage
Yes No
Do you want contents replacement cost coverate?
Contents Replacement Cost Coverage
Yes No
Questions or Comments
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
ANNUITY MANAGERS AGENCY, LLC

11 Catherine Place | Katonah, NY 10536
Phone (877) 676-9900
Fax (914) 931-8400
 
 
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