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Personal Information * Last Name * First Name Street Address City State Zip Code Phone Number Alternate Telephone Fax Number * Email Address Age of oldest owner Property Information Property Street Address City State Zip Code Purpose of Use -Select- Owner-Full Time Seasonal - Owner Occupied Rental Commercial If commercial, how is it used? What is the mobilehome park's name? (if on private property, please indicate) What is the number of spaces in the park? What year was it built? What is the serial number? What is the mobilehome manufacturer name? What is the current loan amount? Is the mobilehome tied down? Yes No Is the mobilehome fully skirted? Yes No Is it located within city limits? Yes No Does the mobilehome park have a full-time resident manager? Yes No Is it located on private property?(not in a park) Yes No Have you ever been refused insurance in the last 3 years? Yes No Is it located in a landslide Area? Yes No How many stories? If two stories, what is the ground floor square footage? What is the total square footage of the dwelling? Length and width of mobilehome What is the construction type? -Select- Brick Stone Frame Masonry Superior Log Cabin Frame-Stucco Masonry Veneer If structure is located in a flood zone, what is the distance to body of water? -Select- Do not live in flood zone Less than 100 ft 100-500 ft 500-1000 ft More than 1000 ft What type of roof covering? Was the roof updated? Yes No If yes, what year? What is the distance to fire protection? -Select- 1000 ft or less to hydrant and 5 mi or less to fire station Over 1000 ft to hydrant and 5 MI or less to fire station Over 5 and up to 10 MI to fire station Over 10 MI to fire station Is the building in the brush? Yes No Is there a brush hazard within one mile of the building? Yes No If yes, has the brush been cleared by 250 feet from all sides of the building? Yes No Is there a smoke alarm? Yes No Is there a fire extinguisher? Yes No Are there deadbolts? Yes No Is the electrical updated? Yes No Are there circuit breakers? Yes No Does the electrical circuit box have copper wiring? Yes No How old is the heating/ air conditioning? Is the heating / air conditioning thermostatically controlled? Yes No What is the energy source? -Select- Yes No What is the heating system? -Select- None Heat Pump Electric Gas Oil What is the cooling system? -Select- None Central Air Evaporative Cooler Has the plumbing been updated? Yes No Is the plumbing copper? Yes No Does the mobilehome have a woodstove? Yes No Does the mobilehome have a fireplace? Yes No Does it have interior automatic fire sprinklers? Yes No Is there a theft alarm? Yes No Is there a fire alarm? Yes No What is the earthquake zone? Has it been earthquake retroffited? -Select- Not required - home built after 1975 Yes recently been bolted - retrofitted for EQ No Are there dogs on the property? Yes No If yes, how many and what is the breed of each dog? Are there any other pets or animals on the property? Yes No If yes, how many and what is the description of each? Current Coverage Information Current Insurance Company Expiration Date Were there any losses or claims in the last 5 years? Yes No If yes, what is the date, amount paid and description of each loss or claim? Desired Coverage Information Dwelling Amount - Coverage A Other Structures - Coverage B Business Property - Coverage C Loss of Use - Coverage D Premise Liability - Coverage E -Select- 100,000 300,000 500,000 Policy Deductible -Select- 100 250 500 750 1000 2500 5000 If earthquake insurance is requested, select deductible percentage % -Select- None 10% 15% 20% 25% 30% Do you want building replacement cost coverage? Yes No Do you want contents replacement cost coverage? Yes No Questions or Comments Best Time To Contact You Please let us know the best time to call and discuss your quote. Morning Afternoon Evening Anytime Or Specify Other: Before submitting, type in required validation security code: g774l8