• Please provide data below for a Mobile Home Quote.

  Name
  Work Phone
  FAX
  E-mail

• Owner occupied or tenant?

  
  

• Insured now, not insured, or New Purchase?

  
  

• The County home is located?

  
  

• Inside or Outside City Limits?

  Yes No
  

• Miles from City Limits if Outside of Town?

  
  

• Distance to Fire Hydrant?

  
  

• Dwelling Value?

  
  

• Contents Value?

  
  

• Replacement Cost or Actual Cash Value?

  
  

• Glass Coverage?

  Yes No
  

• Limits of Liability?

  25,000 50,000 100,000 300,000 500,000 1,000,000
  

• Medical Limits?

  500 1000 2000 3000 4000 5000
  

• Deductible Limits?

  250 500 1,000 2,000 1% 2%
  

• Length & Width of Home?

  
  

• Make of Home

  
  

• Type of Siding?

  Vinyl Masonite Hardi Wood Brick Stone
  

• Year Built?

  
  

• Type of Roof?

  
  

• Age of Roof?

  
  

• Number of Layers of Roof?

  1 2 3
  

• Tied Down

  No Yes
  

• Any Plumbing Updates?

  
  

• Any Electrical Updates?

  
  

• Type of Heating?

  Central Heat Gas Space Heaters Electric Window Unit Heat
  

• Type of Cooling?

  Cenral Air Window Unit
  

• Wood burning Stove?

  No Yes
  

• Number of Bedrooms?

  
  

• Number of Baths?

  Attached or Detached Garage?

  Attached Detached
  

• Size of Garage?

  0 Car 1 Car 2 Car 3 Car 4 Car
  

• Size of Carport?

  0 Car 1 Car 2 Car 3 Car
  

• Swimming Pool?

  No Yes

• Swimming Pool Fenced?

  No Yes

• Any Trampoline?

  No Yes

• If any pets list type, breed, and any bit history.

  
  

• Any Deadbolts?

  No Yes

• Any Smoke Alarms?

  No Yes
  

• Any Fire Extinguisher?

  No Yes

• Occupation?

  
  

• Any Business on Premises of Property?

  
  

• Number of Acres?

  
  

• Any Stock Ponds?

  
  

• If a Barn is present, please list size, construction material and use.

  
  

• If any Livestock, please list the breed and number of head.

  
  

• Please list any equipment and value of unit.

  
  

• Have there been any claims in the last 5 years?

  
  

• Remarks

  
  

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Copyright © 2003 [OrganizationName]. All rights reserved.
Revised: 05/07/08