MOBILE HOME APPLICATION

Applicant's Name:
Mailing Address:
City    State    Zip
County:

PROPOSED EFFECTIVE DATE:
12:01 A.M. Standard Time at the address of the Applicant
Home Phone:     Work Phone:
Best Time To Call:  
Fax: Email Address:

 CURRENT INSURANCE INFORMATION
  Company Name (not agency):     Policy Expiration Date:     Amount insured for: $
 Premium Amount: $    Term:      If Other:

 Prior Losses in last 3 years (include description, date & amount):

 MOBILE HOME INFORMATION
 Year:     Make:    Model:

 How is mobile home used? Primary Home     Secondary       Tenant

 Length:    Width:     Is it a modular home? Yes      No

 Serial Number:    Date of Purchase:    Purchase Price:

 Mobile Home in a Park? Yes   No        Lot Number      Park Number

 Do you own the land where home located? Yes   No        Inside city limits? Yes   No       

 Type of Siding:

Wood-burning stove?
Yes   No
Fireplace?
Yes   No
Home Tied Down?
Yes   No
Skirted?
Yes   No

 COVERAGE
 Current Value (excluding land): $
 Value of Adjacent Structures (detached garage, etc.): $
 Personal Articles: $

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.


 Application Completed By:     Date: