Mobile Home Questionnaire

Name

Name (Spouse)

Date of Birth

Date of Birth (Spouse)

Phone Number

Email Address or Other Contact

Location Address including County (Please also list mailing address if different)

Is this home Primary, Secondary or Seasonal

Property Info:

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]?)

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

Central Air
YesNo

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 Info:

Current coverages
(Include company, due date, coverages, deductible & endorsements)

Additional Info:

Purchase Date

# 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, bike/skate ramp or trampoline on your property? (If yes, what?)

Do you have any pets? (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.