| Name * |
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| Marital Status * |
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| Spouse/Partner's Name: |
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| Address: * |
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| Phone Number: * |
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| E-Mail Address: * |
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| Your Date Of Birth: * |
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| Spouse/Partner's Date Of Birth: |
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| Is This Mobile Home Located In A Park? * |
No Yes |
| Year Of Mobile Home: * |
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| Make Of Mobile Home: |
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| Model Of Mobile Home: |
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| Length Of Mobile Home: * |
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| Width Of Mobile Home: * |
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| Are There Any Add-Ons To The Mobile Home, Such As Rooms, Decks, Or Porches? If Yes, Please Describe: * |
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| What Type Of Siding Is On Mobile? * |
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| Is The Roof Flat Or Peaked? * |
Flat Peaked |
| What Type Of Roof? * |
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| Is This A Year-Round Home or Seasonal Home? * |
Year-Round Seasonal |
| What Type Of Foundation Is The Mobile On? * |
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| What Type Of Furnace Fuel Is Used? * |
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| If You Answered "Other" To Above Question, Please Describe: |
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| Do You Have Any Wood, Pellet, Corn, Coal Or Other Type Of Stove Used For Heating? * |
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| Do You Have Any Fireplaces In The Mobile? * |
No Yes |
| Does Your Mobile Have Smoke Detectors? * |
No Yes |
| Do You Have A Fire Extinguisher In The Mobile? * |
No Yes |
| Do You Have Air Conditioning Or Central Air? * |
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| Is The Mobile Within 1,000 Feet Of A Fire Hydrant? * |
No Yes |
| Is The Mobile Within 5 Miles Of A Fire Department? * |
No Yes |
| Do You Currently Have Insurance On Your Mobile Home? * |
No Yes |
| If You Answered "Yes" Above, What Company, And What Coverages Do You Currently Have? |
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| How Much Coverage Would You Like On Your Mobile Home? * |
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| How Much Personal Property Coverage Would You Like? (50% Of Mobile Home Coverage Is Automatic) * |
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| What Deductible Would You Like? * |
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| How Much Liability Coverage Would You Like? * |
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| Many Companies Offer Discounts If You Have Multiple Policies With Them. Do You Currently Have Any Other Insurance Policies In Force, And With What Company? * |
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| Some Of Our Companies Use Credit-Based Insurance Scoring, So Please Either Enter Your Social Security Number, Or Call Us With It, So That We May Provide You With An Accurate Quote. |
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| How Would You Like Us To Contact You Back? * |
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| Verification: |
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