Quote Manufactured Home

MANUFACTURED HOME USE

Name of person completing this form. Include email, phone number and company name if applicable.

Is this a course of construction policy quote request?

Yes

No

If applicabe please provide name and address of contractor. Include licene nubmer too if possible

Do you have insurance currently?*

Yes

No

Approximately how much is the structure insured for now?

Expiration Date of current insurance

Name of current insurance carrier and expiration date

Is the structure to be insured located in a mobile home park?

Yes

No

Name of Park

Please select all boxes that apply*

Owner Occupied Primary Home

Owner Occupied Seasonal home

Tenant Occupied long term rental

Tenant Occupied Vacation Rental Short term

Vacant

What is your primary physical address?*

Street Address City State ZIP Code

Do you have more than one home at this location?*

Yes

No

Property address where dwelling is located*

Street Address City State ZIP Code

Please tell us about the second home

OWNER(S) NAMES AS IT APPEARS ON TITLE

How many names on title?*

1. First Name*

First Last

Date of birth*

Email*

Phone*

Occupation*

Second Name

First Last

Date of birth

Occupation

PRIMARY DWELLING UNDERWRITING

Year of construction

Name of Manufacturer if known

Width and length

Is this a single, double or triple wide

Square Footage

Number of Stories

Siding Material type:

Check all that apply

Hard wired smoke alarms

Battery functioning smoke alarms

Fire Extinguisher

Dead Bolts

Central Station Fire alarm

What is the primary source of thermostatically controlled heat?

Do you have a wood stove?

Yes

No

Garage type (if none state "none"

Approximate Square Footage of Garage

Would you like to add any comments or remarks at this point?

Yes

No

Comments or Remarks

Do you have air conditioning?

Yes

No

Air conditioning type. Swamp, Central

Is there a trampoline?

Yes

No

Is there interior fire sprinklers?

Yes

No

Foundation Type

Any Decking / decks

Yes

No

Tell us about the decks. How many, square footage

Is there a swimming pool?

Yes

No

OUTBUILDINGS - DETACHED GARAGE, BARNS

Describe all other dwellingS

Please include year built, square footage, number of stories. We may have additional questions later.

What is the name of your responding Fire Department?

If you do not know we will research this for you.

What is the approximate distance to a fire hydrant?

Estimated distance to the closest fire department

Any claims in the last 5 years?

Provide estimated date of claim, claim type and amount paid

Do you have items of high value that you want to schedule?

Yes

No

Do not understand and would like to discuss

Examples would be jewelry, paintings, collectibles

If this is for an escrow closing do you want to provide the lender and title information now?

Yes

No

SCHEDULED PERSONAL PROPERTY

Would you like to list items that need to be scheduled on your home insurane policy?

No items to schedule

Yes I want to list them now

Later but yes, I do have items to schedule

Name of item, value and date last appraised or purchased

Notes, Questions or Comments

Title Company Information

Escrow Officer's name

First Last

Title Company's Phone Number

Fax number to title company:

Escrow Officer's Email Address (not required)

Title Company's Name

First Last

Title Companies Address (at the minimum provide City)

Street Address City State ZIP Code

Escrow number if you have it (not required)

Current Mailing Address if different than dwelling address

Street Address City State ZIP Code

Liability limit and Deductible

Medical (required)

Comprehensive Personal Liability or Owner Landlord & Tenant Liab.

If owner occupied you must have CPL. If tenant occupied you must have OL&T. If Tenant occupied this will be quoted as a DP3 / Dwelling Fire Policy. In some instances we will quote a DP1. All the replacement forms type will be discussed with you later.

Personal Umbrella limit:

Deductible (this is your self-insuring limit)

The deductible applies to Coverage A: Dwelling, Coverage B: Outbuildings and detached structures and Coverage C: Personal Property.

Are there any "other" home/dwelling claims?

Yes

No

List dates, type and amount of loss for each

Are any of the dogs mixed with or are pit bull, doberman, roteweiler aikia, wolf or an animal with a prior bite history?

Yes

No

OPTIONAL PHOTOS OR DOCUMENT UPLOAD

Feel free to upload any photos or insurance documents. Photos and documents are reviewed free of charge and allow us to have a better picture of your needs. No pun intended. ")

You may upload up to 10 documents

Drop files here or

Accepted file types: jpg, jpeg, pdf, Max. file size: 1 GB, Max. files: 10.

File format must be either .jpeg or .pft only.

Acknowledgement; By submitting this information you understand that you ARE NOT covered or bound. All information is used to "quote" your insurance. An agent will contact you with a quote.*

Yes, I understand and Agree

No, I do not understand or agree

We cannot proceed if you do not understand and agree that no coverage will be bound at this time. Do you want to change your answer?

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