Mobile Home Insurance

Items Marked in Yellow
are Required Fields

We want to be sure to get the best rate possible, so please answer as accurately as you can.
You are on a Secure Site and we will never sell or trade
any of the information you provide us.
 To give you the best and most accurate quote Please Provide as much information as possible.
   
Policy Term Use * Rental Manufactured Homes Require Effective Date

Years

  

Commercial Application, Form 2002

         
Must be Named on the Title  and Reside in the Home. N/A to Tenant Primary First Name Primary Last Name Date of Birth Social Security #
       
Must also Reside in Home Secondary First Name Secondary Last Name Date of Birth Social Security #
   
 

Email Address

  
 

 

  
     
     
Complete if a Second Insured is to be Named on the Policy Is the Second  Insured a Family Member Related to the Named Insured ? YesNo
If No, is the Second Insured also Named on the Title? (N/A to Tenant Policies) YesNo
 
How Names Should Appear on Declaration Page (If Different from Above)

Primary Name

Secondary Name

Any Insured Retired (NJ, NY only) Manufactured Home in Park ? Manufactured Home Located inside City Limits?
YesNo YesNo YesNo
Park Name Lot Number Park Number County County Code City Code
Address City State Zip Code
     
   

Manufactured Home Information

   Primary Mailing Address
Make Model Year Width Length   Same as Manufactured Home Location
  Address Line 1
Woodstove or Fireplace ?  
No Factory Installed Commercially Installed Self Installed Address Line 2
Manufactured Home Tied Down ?   
YesNo   City or Town
    Date of Purchase                       Purchase Price  
                                  $   State
What is the Value of the Manufactured Home ? (Excluding Land)    
$   Zip Code
Is this a Multi-Sectional Mobile Manufactured Home?  
YesNo   Home Telephone Number
Is this a Modular Home ?    
YesNo   Work Telephone Number
Is Other Structure Limit Higher than Package Limit ?      EXT
YesNo    If Yes, Indicate New Amount    Please List all Claims within the Past 5 Years
Does Manufactured Home Have an Addition Exceeding 400 sq. ft  
YesNo  

Rhode Island Only: Has any been convicted of any degree of arson during past 10 years? (Failure to disclose any arson conviction is a misdemeanor punishable by not more than 1 year of imprisonment)

  
YesNo  

North Carolina Only: Is the Manufactured home located within 1500' of any River, Creek, Canal or Tidal Water OR on a Site that was Previously Flooded?
If yes, do not Bind Coverage, the risk is UNACCEPTABLE

  
YesNo