Mobile-Home-Form

McCaleb Insurance Agency

662-746-1100

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FILL OUT THE FOLLOWING AND SUBMIT FOR A MOBILE HOME QUOTE

NAME:

ADDRESS:

ZIP:

STATE:

CITY:

OCCUPATION:

PHONE:

EMAIL:

CONFIRM EMAIL:

CURRENTLY INSURED?

If yes, list carrier and # of years continuous.

HOME ADDRESS:

ZIP:

STATE:

CITY:

COUNTY:

DESCRIPTION OF RISK:

MOBILE HOME YEAR:

MOBILE HOME MAKE:

MODEL:

SERIAL #:

IS MOBILE HOME SKIRTED?

IS THERE A FIREPLACE?

IF YES, IS IT FACTORY INSTALLED?

DO ALL THE STEPS HAVE RAILINGS?

DISTANCE TO FIRE STATION:

MARKET VALUE: $

AMOUNT OF COVERAGE:

MILES

A. DWELLING $

B. OTHER STRUCTURES $

C. PERSONAL PROPERTY $

D. LOSS OF USE $

E. PERSONAL LIABILITY $

F. MEDICAL PAYMENTS $

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?

UNDERWRITING QUESTIONS:

BIRTHDAY: