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ABOUT YOUR MOBILE HOME /
MANUFACTURED HOME |
| Year Built: |
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Size (in sq feet):
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Length: |
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Width:
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| Community: |
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| Name of Park: |
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| Manufacturer & Model: |
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How would you describe your home: |
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Stories: |
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| Skirted: |
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| Foundation: |
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If you have a permanent foundation, you may qualify
for a different type of policy. |
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Usage: |
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COVERAGE OPTIONS |
| Structure Coverage
Requested: |
$
(amount needed to rebuild your home - please
provide an estimate) |
| Purchase Price: |
$ |
| Liability Limits: |
$50k$100k
$300k
$500k |
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Extra
Personal Property Coverage: |
$
(optional, beyond the
already included portion) |
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| Other: |
Do
you have a pet? If yes, choose amount of animal coverage:
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Prior
losses or claims?
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Woodburning Stove? |
| Seniors: |
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| Construction:
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Roof Type:
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| Mortgage: |
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| Earthquake Coverage: |
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| Flood Coverage: |
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| Extras: |
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Is the dwelling within 500 feet of
native brush, or isolated or inaccessible to fire fighting
equipment?
Yes
No
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Do you currently have insurance (if
yes, with what carrier?
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What is your current yearly or
monthly premium? |
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| Prior Claims #1: |
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| Prior Claims #2: |
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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. |
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