Manufactured Home Quote Form
For Rental on Motor Home also

APPLICANT INFORMATION
First Name:
Last Name:
Address: 
City:
State:
Zip:
Phone:
Email: Original Owner Yes No  
Date of Birth :   Social Security #:  
Year/Make/Model:  Serial #: Size:     
Occupancy? Owner Tenant                 Purchase Date:       Price:$
Mobile Home Park: Yes No                 Number of Spaces: Private Property: Yes No
Tied Down: Yes No                               Permanent Foundation: Yes No Land Owned: Yes No
Inside City Limits: Yes No                   Distance to Fire Dept: Fire Hydrant:
Responding Fire Department:    
Protection Class: County: Mortgage:  Yes No  
Who: Amount of Coverage:  Deductible:     
Personal Liability:       Content Coverage: Yes No Amount:  
Other Structures:   Yes No Protective Siding? Vinyl Wood    
Type of Heat:  Electric Gas Trampoline? Yes No    
Swimming Pool:  Yes No     If Yes Above Ground In Ground Fenced: Yes No  
Animals:  Yes No       If dog what breed? Has it ever bitten anyone? Yes No
Currently Insured: Yes No With: Expires:
Claims in the last 5 years:
Any Items to Schedule: Yes No If yes, what:  
How did you hear about our Agency?: