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    •  
    Mobilehomeowners Insurance
    Quotation Form
    One Simple Form - takes only 2-3 Minutes!
    Your Personal Data:
     
    Your Name:
    Property Address:
    City:
    State: (Must be Washington)
    Zip/Postal:
    E-Mail (REQUIRED):
    Phone:
    Fax (optional):
    Primary Insured's Occupation:
     
    Owners Date of Birth?
    (Some carriers use birthdates for additional discounts)
    Current Home Lender & Loan Amount?
    (Some carriers require
    for replacement values)
     
    Dwelling Information
     
    Year Home Built:
    Home Square footage:
     
    Describe this Modular
    or Mobile Home:
    (Year, Make, Model)
     
    Dimensions
    (Length X Width)
     
    Number of units: 1 family Duplex
     
    Occupancy Type: Owner occupied
    Tenant occupied
    Seasonal Dwelling
    Vacant or For Sale
    (describe in remarks if vacant or for sale.)
     
    Mobilehome Location: Inside City Limits
    Inside park
    Inside Subdivision
    (describe Park name, or subdivision name below, if any:)
     
     
     
    Type Roof: Shingle Wood Shake
    Tar/Gravel Metal
    Metal Other
     
    Is mobilehome tied down? Yes No
     
    Does mobile home have skirting? Yes No
     
    Are there handrails on steps and decks? Yes No
     
    Is there a trampoline on premises? Yes No
     
    Do you own animals or pets? Yes No
     
    If yes, list type/for dogs, list breed:
     
    Do you have a swimming pool? Yes No
    If yes, list descibe fencing and diving board:
     
    Other structures/outbuildings on premesis? Yes No
    If yes, describe outbuildings and values:
     
    Fire Protection:  
     
    # of feet to nearest
    fire hydrant:     		# of miles to nearest
    fire station:
     
     
    Plumbing type: Copper Galvanized
    Mixed (Copper/Galvanized)
    PVC
     
    Circuit Breakers or fuses? Breakers Fuses
     
    Heating Type (central thermostat?):
     
    Fireplace or Woodburning Stove? (If yes, describe):
     
    Any business conducted on premises?
    (SIf yes, please describe in detail):
     
    Currently Insured? Yes No
     
    Current Carrier and Expiration Date?
     
    Past bankruptcies or reposessions?
    (If yes, describe in detail):
     
    Prior Claims? Yes No
    (If yes, describe claims in detail, and how problems corrected):

    # Bedrooms: # Bathrooms:
     
    Garage or Carport?: # of cars, attached/detached?
     
    Special features
    (i.e., deck, air conditioning, alarm systems, jacuzzi, screened porch, etc.)
     
    Coverages:
     
    Dwelling Cov. $ Contents $
    Liability Cov. $ Deductible $
    ($500, $1,000, $2500):
     
    Comments/Remarks
    (describe any scheduled jewelry, in-home business, or other special coverages needed here):
     
    Send my quotation via: E-Mail Fax
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    1011 E. Main Street, Suite 204 B   |    Puyallup, WA 98372 (Click for Map/Directions)
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