Personal Information
*First Name
*Last Name
Mailing Address
City/St/Zip
*Phone Number
Alternate Number
Age of oldest owner
*Email Address
Mobilehome Information
Property address:
Property Street Address
Purpose of Use
[select purpose "-Select-" "Owner-Full Time" "Seasonal-Owner Occupied" "Rental" "Commercial"]
If Commercial, how is it used?
What is the mobilehome park's name? (if on private property, please indicate)
Located on private property: Yes No
What year was the mobilehome built?
What is the mobilehome serial number?
What is the mobilehome manufacturer name?
Is the mobilehome tied down?
Yes No
Is the mobilehome fully skirted?
Yes No
Is it located within city limits?
Yes No
Does the mobilehome park have a full-time resident manager?
Yes No
Have you ever been refused insurance in the last 3 years?
Yes No
What is the total square footage of the dwelling?
Length and width of mobilehome
If the mobilehome is located in a flood zone, what is the distance to body of water?
-Select- Do not live in flood zone Less than 100 ft 100-500 ft 500-1000 ft More than 1000 ft
What type of roof covering?
Was the roof updated?
Yes No
If yes, what year?
What is the distance to fire protection?
-Select- 1000 ft or less to hydrant and 5 mi or less to fire station Over 1000 ft to hydrant and 5 MI or less to fire station Over 5 and up to 10 MI to fire station Over 10 MI to fire station
Is there a smoke alarm installed?
Yes No
Is there a fire extinguisher?
Yes No
Are there deadbolts?
Yes No
Is the electrical updated?
Yes No
Are there circuit breakers?
Yes No
Does the electrical circuit box have copper wiring?
Yes No
How old is the heating/ air conditioning?
Is the heating / air conditioning thermostatically controlled?
Yes No
What is the heating system?
-Select- None Heat Pump Electric Gas Oil
What is the cooling system?
-Select- None Central Air Evaporative Cooler
Has the plumbing been updated?
Yes No
Is the plumbing copper?
Yes No
Does the mobilehome have a woodstove?
Yes No
Does the mobilehome have a fireplace?
Yes No
Does the mobilehome have interior automatic fire sprinklers?
Yes No
Is there a theft alarm?
Yes No
Has the mobilehome been earthquake retroffited?
-Select- Not required - home built after 1975 Yes recently been bolted - retrofitted for EQ No
What is the fire district?
Are there dogs on the property?
Yes No
If yes, how many and what is the breed of each dog?
Are there any other pets or animals on the property?
Yes No
If yes, how many and what is the description of each?
Current Coverage Information
Current Insurance Company
Expiration Date
Were there any losses or claims in the last 5 years?
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Desired Coverage Information
Dwelling Amount - Coverage A
Other Structures - Coverage B
Personal Property - Coverage C
Loss of Use - Coverage D
Premise Liability - Coverage E
-Select- 100,000 300,000 500,000
Policy Deductible
-Select- 100 250 500 750 1000 2500 5000
If earthquake insurance is requested, select deductible percentage %
-Select- None 10 15 20 25 30
Do you want building replacement cost coverage?
Yes No
Do you want contents replacement cost coverage?
Yes No
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote
Morning Afternoon Evening Anytime
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