Form

Mobile Home Quote
Submission Form

*Marks Required Fields

*Agency Name:

GRI Producer Code:

Quote Submission Form Completed by:

*Agency Fax #:

*Agency Email #:

Quote Needed By:

*Applicant Name:

*Applicant DOB:

*Applicant SSN:

In connection with this quote for insurance, companies may review your applicant's credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. They may use a third party in connection with the development of your applicant's insurance score. They may also obtain loss history and other consumer reports using a third party. The above information may be used to develop a premium.

* Occupancy
Primary Residence: Package Monoline
Seasonal Rental
(Vacant Mobile Homes may be written through the DP-1)

Location

State County Location Zip

Address 1
Address 2
City
State
Zip

In Park Private Property
Distance from Fire Station (in miles) Protection Class

Mailing Address

Address 1
Address 2
City
State
Zip

Mobile Home Description
* Age of Home: (Not Eligible if over 25 years)
* Length and Width:
Manufacturer: (Must be listed in NADA)
Siding TypeWood Masonite Vinyl Metal Other
Purchase Price Purchase Date

Underwriting
* Any Bankruptcy, Foreclosure, or Reposession in the last 5 years?
Yes No

* Does insured have a Wood, Coal or Pellet Burning Stove, Space Heater, Kerosene Heater? (If Yes, photos must accompany applications)
Yes No
If Yes, what is the Primary Heat Source?

Is it thermostatically controlled? Yes No

* Any animals on premises?
Yes No
If Yes, what kind(s):
If needed, add animal liability exclusion or submit application without liability coverage.

* Any Farming or Business operations on premises? Yes No

* Swimming Pool: Yes No
If Yes, is it fenced with a locking gate that is at least 4 feet high? Yes No

* Trampoline: Yes No
If Yes, is it fenced with a locking gate that is at least 4 feet high? Yes No

* Loss History Past Five Years:

Has applicant had coverage in the last 30 days? Yes No

Limits & Premiums
* Dwelling Limit: $
* Personal Property: $
* Adj. Structures: $
* Liability: $
* Increased Med. Pay: $
* Deductible Option: $

Endorsements:
Do you want Earthquake Coverage: Yes No

Do you want Replacement Cost for Partial Loss? YesNo
Subject to age restrictions. Dwelling limit must equal replacement value.
Do you want Replacement Cost for Contents? Yes No

Additional Coverages Requested:

This will be a price indication only and is subject to change. Factors which can affect the premium include underwriting criteria or company rate changes recently updated. This submission will generate a quote only and not for intended for policy issue.

Mobile Home QuoteSubmission Form

Mobile Home Quote
Submission Form