ABOUT YOUR MOBILE HOME
Year Built:		Size (in sq feet):
	Length:    Width:
Community:	CHOOSE ONE Open Area - Not Fenced Lighted and Fenced Community Lighted, Fenced Community with Security
Name of Park:
Manufacturer:
Stories:	0 1 2 3 4
Structure Coverage:	$
Gated:	CHOOSE ONE NO GATE YES - THE COMMUNITY IS GATED YES - GATED WITH 24 HOUR SECURITY GUARD
Skirted:	CHOOSE ONE Yes - Fully Skirts Yes- Partially Skirted No - Not Skirted
Usage:	CHOOSE ONE OWNER OCCUPIED I RENT OUT MY HOME TO OTHERS (LANDLORD POLICY) I AM RENTING A MOBILE HOME
Liability Limits:	$50k$100k $300k $500k
Extra Personal Property Coverage:	$ (optional, beyond the already included portion)
Other:	Do you have a pet?   If yes, choose amount of animal coverage: No Coverage $25,000 $50,000 $100,000 $300,000
	Prior losses or claims? Woodburning Stove?
	Swimming Pool?           Trampoline?
Seniors:	CHOOSE ONE Yes -All Owners are 50 or older No - All owners are not over 50
Construction:	CHOOSE ONE Vinyl Masonry Aluminum Wood    Roof Type: CHOOSE ONE Composition (Asphalt) Tile Metal
Mortgage:	CHOOSE ONE YES - I have a mortgage No - I do not have a mortgage
Earthquake Coverage:	CHOOSE ONE YES - Please add it with a 10% deductible YES - Please add it with a 15% deductible NO - Do not quote earthquake coverage
Flood Coverage:	CHOOSE ONE YES - Please add it to the quote NO - Do not quote flood coverage
Extras:	CHOOSE ONE Yes - Add Golf Cart Coverage No - Do not add golf cart coverage
	Is the dwelling within 500 feet of native brush, or isolated or inaccessible to fire fighting equipment? Yes     No
	Do you currently have insurance (if yes, with what carrier?
	What is your current yearly or monthly premium?
Prior Claims #1:	CHOOSE ONE NO Claims in the last 5 years Yes - Theft Claim Yes - Property Claim Yes - Liability Claim
Prior Claims #2:	CHOOSE ONE NO Claims in the last 5 years Yes - Theft Claim Yes - Property Claim Yes - Liability Claim
	Do you have any other information about your rental or apartment, or comments that you would like to share? Please place special requests here, such as extra coverage for special items.