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Angela Standish
2023-10-12T15:41:01-05:00
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Manufactured Home Quote
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Country
United States (US)
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Belau
Belize
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Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
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Bouvet Island
Brazil
British Indian Ocean Territory
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Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Costa Rica
Croatia
Cuba
CuraÇao
Cyprus
Czech Republic
Denmark
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Ecuador
Egypt
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Equatorial Guinea
Eritrea
Estonia
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Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Republic of Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
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Kuwait
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Laos
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Lebanon
Lesotho
Liberia
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Lithuania
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Macao S.A.R., China
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Maldives
Mali
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Moldova
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Montserrat
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Nauru
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Netherlands
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New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
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Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
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Russia
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Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Martin (Dutch part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
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Saudi Arabia
Senegal
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Somalia
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Spain
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Sudan
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Togo
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Zip code
Mailing address same?
*
Yes
No
Dwelling Settlement Option:
*
Actual Cash Value
Replacement Cost
Residence Type
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1 Family Residence
2 Family Residence
3 Family Residence
4 Family Residence
Other - Specify
Occupancy:
*
Owner
Rental
Seasonal
Vacant
Reason for vacancy:
*
Is the dwelling in a park of 26 or more spaces?
*
Yes
No
Underwriting:
Year Built
*
Model Year
*
Style:
*
Single-Wide
Multi-Wide
Length
*
Width
*
Are there any attached structures?
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Yes
No
Describe Attached Structures:
Year of roof:
Type of roof:
*
Construction Type:
*
Number of Stories:
*
Square Footage of Building:
*
Do not include the basement (finished or unfinished) in Finished Living Area.
Protection Class:
Foundation Type:
*
Basement - Below Grade
Basement - Walk Out
Crawl Space
Hillside
Open
Pier and Post/Stilts
Slab
Other - Specify:
Roof Slope/Style:
*
Flat
Slight Pitch
Moderate Pitch
Steep Pitch
Gambrel
Mansard
Shed
Is the primary heat source thermostat controlled?
*
Yes
No
Heating Type:
*
Gas
Electric
Other - Specify:
Estimated Valuation
*
Discounts & Surcharges - Documentation for some discounts may be required and can be uploaded below
Will the applicant enroll in paperless policy delivery?
*
Yes
No
Applicant's email address:
*
Will this be mortgagee billed?
*
Yes
No
Will the applicant be paying in full?
*
Yes
No
Does the applicant have more than 1 AMIG policy with Graham-Rogers?
*
Yes
No
Please advise the policy number:
*
Does the applicant have their auto policy written with your agency?
*
Yes
No
Has there been any claims for ALL properties owned in the last 3 years?
*
Yes
No
Has the applicant had similar insurance declined, cancelled, or non-renewed?
*
Yes
No
Reason for prior decline, cancellation, or non-renewal:
*
Prior Loss History
Payment Problems
Physical Hazard or Condition
Carrier No Longer Writes in State
Carrier No Longer Writes This Type of Business
Applicant No Longer Belongs to Association or Group
Other
Describe Other
*
Number of dwellings owned?
*
Is the applicant a member of AAA, USAA or Landlord Association?
*
Yes
No
If Yes, please attach documentation below.
Loss Type
*
Date of Loss
*
Amount of Loss
*
Explain cause, details and damages of loss
*
Add another claim?
*
Yes
No
Loss Type?
*
Date of Loss?
*
Amount of Loss?
*
Explain cause, details and damages of loss?
Add another claim:
*
Yes
No
Loss Type:
*
Date of Loss:
*
Amount of Loss:
*
Explain cause, details and damages of loss:
*
Any Farming or Business operations on premises?
*
Yes
No
Explain what Farming or Business operations on premises:
Any Animals or Pools?
*
Yes
No
Please select which:
Animals
Pools
Explain type of animals:
*
Number of animals:
*
Type of pool:
*
Fencing or security measures for pool:
*
Will the dwelling be occasionally rented to others?
*
Yes
No
Has the dwelling gone uninsured?
*
Yes
No
Number of days uninsured?
*
Is the building under construction/renovation?
*
Yes
No
Supplemental Heating Source (including wood/pellet burning stove)?
*
Yes
No
Any central or local alarms?
*
Yes
No
If Yes, please attach documentation below.
Please advise alarm information:
*
Deadbolts, Fire Extinguishers & Smoke Alarms:
*
Yes
No
Property Purchase Date:
*
Purchase Price:
*
Is this a new purchase?
*
Yes
No
Current Carrier:
*
Expiration Date:
*
Coverages:
Dwelling Limit:
*
Detached Structures:
Personal Property:
Personal Property Settlement Option:
Actual Cash Value
Replacement Cost
Deductible:
*
$1,000
$2,500
$5,000
Additional Living Expenses:
Is the applicant wanting Liability Coverage?
*
Yes
No
Liability:
*
Med Pay:
*
Vacant Under Renovation Limit:
*
Total value of dwelling after renovations:
*
Optional Coverages - Some coverages may not apply to all programs
*
None
Earthquake
Theft
Water Backup
Water Damage
Vandalism & Malicious Mischief
Residence Burglary
Identity Recovery
Equipment Breakdown
Service Line
Ordinance or Law
Builders Risk/Renovation (vacant only)
Enhanced Coverage
Hobby Farming
Scheduled Personal Property
Please provide any supporting documentation and photos you may have:
*
Document 2
Document 3
Document 4
Any Additional Questions or Comments?
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