Home/Mobile Home Owner Quote
No coverage
is bound until you are contacted by one of our representatives
CONTACT INFORMATION
Name
Street
Address
Current Mailing
Address
City,
State, Zip
AL
AK
AB
AZ
AR
BC
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MB
MD
MA
MI
MN
MS
MO
MT
NE
NV
NB
NF
NH
NJ
NM
NY
NC
ND
NS
OH
OK
ON
OR
PA
PE
PQ
RI
SK
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Email
Address
Social Security #
Date of birth
Occupation
Employer
How long with current Employer
Phone
Number Home
Work
SPOUSE INFORMATION
Social Security #
Date of birth
Occupation
Employer
Phone
Number Work
HOME TO BE INSURED
Street
Address
Street
Address
City,
State, Zip
AL
AK
AB
AZ
AR
BC
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MB
MD
MA
MI
MN
MS
MO
MT
NE
NV
NB
NF
NH
NJ
NM
NY
NC
ND
NS
OH
OK
ON
OR
PA
PE
PQ
RI
SK
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
How long at present address
Previous home address if less
IF MOBILE HOME
a. Do you own or rent the land
Select One
Own
Rent
b. Is mobile home in a park?
Select One
Yes
No
If yes, park name
c. Mobile home Width & Length
d. Manufacturer Name
e. Model Name
f. Year Built
g. Serial Number
RATING INFORMATION
1. What
year was this home built?
2. What
type of construction was used?
Select One
Frame
Masonry
Aluminum Siding
3. Number of Stories
4. Other Occupancies:
5. Age of Roof
6. Roof Type
Select One
Composition
Metal
Other
If Other
7. What
style is your home?
Select One
Sgl Family Dwelling
Apartment Building
Condominium
8. How
will your home be used?
Select One
Primary Residence
Secondary Residence
Seasonal Home
Farm
Unoccupied
Vacant
9. How
many rooms in your home?
10. How
many full bathrooms in your
home?
11. How
many 3/4 bathrooms in your
home?
12. How
many 1/2 bathrooms in your
home?
13. How
many square feet on the first
floor?
14. What type
of home do you have?
Select One
Single story
Two story
Split entry
Tri-Level
15. How
many total square feet in your
home?
16. Do
you have a fireplace?
Select One
Yes
No
If yes, please describe what type
17. Do
you have a woodstove?
Select One
Yes
No
If yes, please describe type and use
18. Do
you have a garage?
Select One
Yes
No
If yes, please describe what type
Select One
Attached single car
Attached two car
Attached three car
Detached single car
Detached two car
Detached three car
Carport
19. What
is your primary source of heat?
20. What
is your secondary source of
heat?
PROTECTIVE DEVICES:
21. Do
you have a security system?
Select One
Yes
No
If yes, please describe what type
Burgler Alarm
Select One
Yes
No
Type of Alarm
Alarm Company
Sprinkler System In Building
Select One
Yes
No
Smoke Detectors
Select One
Yes
No
22. Have
you had any losses in the past 3
Select One
Yes
No
years?
If yes, please describe
23. Is
this your first home?
Select One
Yes
No
If no, do you have current insurance?
Select One
Yes
No
24.
Do you own any pets?
Select One
Yes
No
If yes, Please describe
25.
Any Hot Tub, Sauna, Swimming Pool,
Select One
Yes
No
Trampoline, wet Bar, Etc.?
If yes, Please describe
26.
Any updates that have been done on
Select One
Yes
No
home (i.e., new roof, electrical, heating, retrofitting, etc).
If yes, Please enter date complete and describe
IF THE BUILDING IS OVER 25 YEARS OLD, PLEASE ANSWER THE FOLLOWING:
27. Year Electricity was Updated
28. Is it on Circuit Breakers
Select One
Yes
No
29. Year Plumbiing was Updated
30. Copper or Galvanized Plumbing
Select One
Copper
Galvanized
Other
If Other
CURRENT INSURANCE
1.
Previous Carrier
2.
Start date
3.
How Long Insured
4.
Amount insured for
5.
Policy Number
7.
Policy Renewal Date
COVERAGE INFORMATION
1.
Dwelling
2.
Contents
3.
Liability
4.
Medical Coverage
5.
Deductibles
All Perils
Wind/Hail/Storm
6.
Loss of Use
ADDITIONAL INSURED
Name
Address
Phone
Number Phone
FAX
Account or Loan #
LIEN HOLDER
Name
Address
Phone #
Fax #
Loan #
Mortgage Clause
Legal description
Please use the space
below to add comments regarding any special circumstances or coverage
needs
About Us | 
