Mobile Home Questionnaire

Comments

This field is for validation purposes and should be left unchanged.

Name(Required)

Date of Birth

Phone Number

Email Address or Other Contact

Name (Spouse)

Date of Birth (Spouse)

Location Address including County

(Please also list mailing address if different)

Is this home Primary, Secondary or Seasonal

Property Information

Year, Make & Model

Single-Wide, Double-Wide or Park Model

Length x Width

Type of Tie-Downs

Additions & Attached Structures (Type & Size)

Garage

(Yes/No, Attached/Detached, # of Vehicles)

Deck, porch, patio, etc

(Yes/No, Type, Size)

Detached Structures

(If yes, what? Heated [If yes, by what]?)

Number of Baths (# of full & # of 1/2)

Central Air

Yes

Fireplace (Yes/No, Gas/Wood/Wood Stove)

Flooring: (% of each type)

Current Market Value

Age & Type of Roof

Age & Type of Heating

Age & type of electric (Circuit Breakers/Fuses)

Security or Sprinkler System (If yes, what?)

Name of Mobile Home Park

Repairs Needed

Current Insurance Information

Current Coverages (Include company, effective date, coverages, deductible & endorsements)

Additional Information

Purchase Date

Number of consecutive years you've carried a homeowner-type policy?

(Including home, condo, mobile home & tenant)

Valuable Contents (Type & Value)

(ie Jewelry, Guns, antiques, artwork, etc)

Property claims in the last 5 years (When & What)

Smoker/Non-Smoker (All residents)

Bankruptcy in the last 5 years? (If yes, when?)

Is there a pool, hot tub or trampoline on your property? (If yes, what?)

Do you have any pets or livestock? (If yes, what breed?)

Business conducted in your home? (If yes, what?)

Deductible options you would consider

Additional Insured

Do you have any toys?

(ie boat, motorcycle, ATV, snowmobile, golf cart, RV, etc)

If you have a copy of your current "Declaration Page", please forward that to us as proof of prior coverage and to use for comparison purposes. Submission of information for a quote in no way binds coverage. Personal information will be used solely for underwriting purposes. Submission of information gives the Gary J Bach Agency permission to run all reports necessary to quote accurate insurance premiums.