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.