Quote Mobile Home Insurance MANUFACTURED HOME USEDo you have insurance currently?* Yes No Approximately how much is the structure insured for now? Expiration Date of current insurance MM slash DD slash YYYY 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have more than one home at this location?* Yes No Property address where dwelling is located* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please tell us about the second homeOWNER(S) NAMES AS IT APPEARS ON TITLEHow many names on title?*Just oneTwo1. First Name* First Last Date of birth* Email* Phone*Occupation* Second Name First Last Date of birth Occupation PRIMARY DWELLING UNDERWRITINGYear of construction Name of Manufacturer if known Width and length Is this a single, double or triple widePlease choseSingleDoubleTripleSquare Footage Number of StoriesSelect12Siding Material type:Please selectMetalStuccoVinylCement fiberWoodT-111Log veneerCheck 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 RemarksDo 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 TypeSelect type of foundaitonCrawl Space BlockCrawl Space Poured ConcreteJacks onlyAny Decking / decks Yes No Tell us about the decks. How many, square footageIs there a swimming pool? Yes No OUTBUILDINGS - DETACHED GARAGE, BARNSDescribe all other dwellingSPlease 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?SelectWithin 1000 feetOver 1,000 feetEstimated distance to the closest fire departmentSelectWithin 5 road milesOver 5 road milesAny claims in the last 5 years?SelectYesNoProvide estimated date of claim, claim type and amount paidDo 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, collectiblesIf this is for an escrow closing do you want to provide the lender and title information now? Yes No SCHEDULED PERSONAL PROPERTYWould 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 purchasedNotes, Questions or Comments Title Company InformationEscrow Officer's name First Last Title Company's Phone NumberFax 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Escrow number if you have it (not required) Current Mailing Address if different than dwelling address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Liability limit and DeductibleMedical (required)Select$1,000$2,000$5,000Comprehensive Personal Liability or Owner Landlord & Tenant Liab.$300,000$500,000$1,000,000Personal Umbrella neededIf 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:Select if you want a quote$1,000,000$2,000,000$3,000,000$5,000,000$10,000,000Deductible (this is your self-insuring limit)Chose$1,000$2,500$5,000$10,000The 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 eachAre 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 UPLOADFeel 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 Select files Accepted file types: jpg, jpeg, pdf, Max. file size: 128 MB, 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?
