FILL OUT THE FOLLOWING AND SUBMIT FOR A MOBILE HOMEÂ QUOTE
If yes, list carrier and # of years continuous.
IF YES, IS IT FACTORY INSTALLED?
DO ALL THE STEPS HAVE RAILINGS?
DISTANCE TO FIRE STATION:
A. DWELLINGÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â $
B. OTHER STRUCTURESÂ Â Â Â Â Â Â $
C. PERSONAL PROPERTYÂ Â Â Â Â Â $
D. LOSS OF USEÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â $
E. PERSONAL LIABILITY       $
F. MEDICAL PAYMENTSÂ Â Â Â Â Â Â $
3. Any previous losses on any properties in the     past five years?
4. Any previous fire losses?
1. Has risk been cancelled, nonrenewed, or declined by another company?
 2. Have you filed bankruptcy in the last five years?
 5. Any animals?
     If yes, please list:
  6. Is there a swimming pool on the premises?
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