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Manufactured Home Quote Request
Your Information
Last Name
*
First Name
*
Email Address
*
Street Address
*
City
*
State
*
Zip Code
*
Phone Number
*
Alternate Phone
Birth Date
*
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Property Information
Property Street Address
City
State
Zip Code
Occupancy Type
Principal Residence
Seasonal Residence (Owner Occupied)
Commercial
Rental
Tenant
County (Location):
Year of Home:
Make & Model:
Length & Width:
Purchase Price: $
In a Park?
Yes
No
If yes, how many spaces in the park ?
If home is Seasonal, is it occasionally rented to others?
Yes
No
Is there any private, not-for-profit farming on premises?
Yes
No
Is there a supplemental heating device?
Yes
No
Does the home have Vinyl or Hardboard siding?
Yes
No
Is the home skirted?
Yes
No
Is the home tied down?
Yes
No
Is the home on a permanent foundation?
Yes
No
Does the home have a composite roof?
Yes
No
Is the home vacant or unoccupied?
Yes
No
Is there a swimming pool on the premises?
Yes
No
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Current Coverage Information
Current Insurance Company
Expiration Date (DD/MM/YYYY)
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?
(500 chars left)
Desired Coverage Information
Dwelling Amount - Coverage A
Other Structures - Coverage B
Personal Property - Coverage C
Loss of Use - Coverage D
Premise Liability - Coverage E
$100,000
$300,000
$500,000
$1,000,000
Policy Deductible
$100
$250
$500
$750
$1000
$2500
$5000
Golf Cart Coverage (# of Carts)
Scheduled Personal Property (Please include a copy of the schedule)
Water Back Up (American Modern only)
Do you want building replacement cost coverage?
Yes
No
Do you want contents replacement cost coverage?
Yes
No
Equipment Breakdown (American Modern only)
Interested in Flood Coverage?
Yes
No
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Afternoon
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Anytime
Questions or Comments
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