What is your first name? ** What is your first name? *
What is your last name? ** What is your last name? *
What is you email address? ** What is you email address? *
What is your phone number? What is your phone number?
What is your occupation? ** What is your occupation? *
What is your employer name? ** What is your employer name? *
What is your date of birth? What is your date of birth?
MM slash DD slash YYYY
What is your marital status? ** What is your marital status? *
Select Single Married Engaged Divorced Widowed Separated
What is your spouse’s full name? What is your spouse’s full name?
What is your spouse's date of birth? What is your spouse's date of birth?
MM slash DD slash YYYY
What is your spouse's gender? What is your spouse's gender?
What is your fiancé’s full name? What is your fiancé’s full name?
What is your fiancé’s date of birth? What is your fiancé’s date of birth?
MM slash DD slash YYYY
What is your fiancé’s gender? What is your fiancé’s gender?
Are there any other legal owners living in the home that should be listed on this policy? Are there any other legal owners living in the home that should be listed on this policy?
How many other legal owners are living in the home? ** How many other legal owners are living in the home? *
Please enter the other legal owner’s information below. Please enter the other legal owner’s information below.
Property & Ownership Information What is the property address? ** What is the property address? *
Is the mailing address the same as the property address? Is the mailing address the same as the property address?
What is your mailing address? What is your mailing address?
What county is the home located in? What county is the home located in?
Are you in the process of purchasing this home? ** Are you in the process of purchasing this home? *
What is the purchase price? What is the purchase price?
What date do you close on this property? What date do you close on this property?
MM slash DD slash YYYY
Is there coverage on the home now? Is there coverage on the home now?
What is the name of the current insurance company? What is the name of the current insurance company?
What is the expiration date of the current insurance policy? What is the expiration date of the current insurance policy?
MM slash DD slash YYYY
What is the current value of this home? What is the current value of this home?
What is the reason the home is not currently insured? What is the reason the home is not currently insured?
Where is this home located? Where is this home located?
What is the name of the Park? What is the name of the Park?
What is the name of the Subdivision? What is the name of the Subdivision?
Are there over 20 homes in the subdivision? Are there over 20 homes in the subdivision?
Is there a paved road in front of this home? Is there a paved road in front of this home?
How far is it to a paved road? How far is it to a paved road?
How many acres does the property have? How many acres does the property have?
How many homes are visible from this home? How many homes are visible from this home?
Do you own the land? Do you own the land?
Is this home located in an over 55 community? Is this home located in an over 55 community?
Is this home located in a gated community? Is this home located in a gated community?
Please select the occupancy of this home. Please select the occupancy of this home.
How many months per year does the owner occupy this home? How many months per year does the owner occupy this home?
Select 1 2 3 4 5 6 7 8 9 10 11 12
How many months per year does the tenant occupy this home? How many months per year does the tenant occupy this home?
Select 1 2 3 4 5 6 7 8 9 10 11 12
Is there any business conducted on the premises? Is there any business conducted on the premises?
Please provide the type of business and a brief description of it. Please provide the type of business and a brief description of it.
Are you a member of AAA or AARP? Are you a member of AAA or AARP?
Manufactured Home Information What year was the home manufactured? What year was the home manufactured?
What is the name of the manufacturer of this home? What is the name of the manufacturer of this home?
Please enter the length and width of the home. Please enter the length and width of the home.
What is the home’s serial number? What is the home’s serial number?
Please select the features included with this home? Please select the features included with this home?
Please enter the length and width of the carport. Please enter the length and width of the carport.
Please enter the length, width and if the screen room is elevated. Please enter the length, width and if the screen room is elevated.
Please enter the length and width of the attached shed. Please enter the length and width of the attached shed.
Please enter the length and width of the unattached shed. Please enter the length and width of the unattached shed.
Please enter the length, width and if the Florida room is glass or vinyl. Please enter the length, width and if the Florida room is glass or vinyl.
Please enter the type and square footage of the fence. Please enter the type and square footage of the fence.
Please enter the type of pool and if it has a 4 foot locking fence or is screened in. Please enter the type of pool and if it has a 4 foot locking fence or is screened in.
How many fold down aluminum awnings are there? How many fold down aluminum awnings are there?
Do all entrances with 2 or more steps have handrails? Do all entrances with 2 or more steps have handrails?
Please enter the other features this home has. Please enter the other features this home has.
Please select this home’s roof type. Please select this home’s roof type.
What year was the roof replaced? What year was the roof replaced?
What type of skirting/underpinning does this home have? (Skirting/Underpinning goes around a manufactured home to enclose the crawl space underneath it.) What type of skirting/underpinning does this home have? (Skirting/Underpinning goes around a manufactured home to enclose the crawl space underneath it.)
Plywood Vinyl Faux Rock Metal Concrete Stucco Cinder Block Brick Fiber Cement Lattice Other
Please enter the type of skirting/underpinning this home has? Please enter the type of skirting/underpinning this home has?
Does this home have central air/heat? Does this home have central air/heat?
Does this home have a heat pump? Does this home have a heat pump?
Fire Protection and Risk Management Information Is there a fire hydrant within 1,000 feet of this home? Is there a fire hydrant within 1,000 feet of this home?
How many miles away is the responding fire department from this home? How many miles away is the responding fire department from this home?
Are there any pets in the home? Are there any pets in the home?
How many pets are in the home? How many pets are in the home?
Please enter the type, breed and weight of the pet(s) in this home. Please enter the type, breed and weight of the pet(s) in this home.
Are any farm animals kept at this home? Are any farm animals kept at this home?
What type of farm animals are kept at this home? What type of farm animals are kept at this home?
What is the age of the hot water heater? What is the age of the hot water heater?
Does this home have any Polybutylene Pipe? (Polybutylene pipe was a type of plastic pipe used in manufactured home’s water pipes that was found to caused microfractures in the pipe that led to burst pipes.) Does this home have any Polybutylene Pipe? (Polybutylene pipe was a type of plastic pipe used in manufactured home’s water pipes that was found to caused microfractures in the pipe that led to burst pipes.)
Does this home have an FPE (Federal Pacific Electric Stab-Lok) panel box? Does this home have an FPE (Federal Pacific Electric Stab-Lok) panel box?
Valuable Articles Do you have any jewelry to be insured over $1,000? Do you have any jewelry to be insured over $1,000?
How many jewelry items do you have to insure? How many jewelry items do you have to insure?
Please enter a description and value for each jewelry item. Please enter a description and value for each jewelry item.
Please upload current sales receipts or appraisals for jewelry items you would like insure. Please upload current sales receipts or appraisals for jewelry items you would like insure.
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End section (Blank) Golf Cart Information Do you have a golf cart at this home? Do you have a golf cart at this home?
Please enter the year, make, and model of the golf cart. Please enter the year, make, and model of the golf cart.
What is the value of the golf cart? What is the value of the golf cart?
What is the serial number of the golf cart? What is the serial number of the golf cart?
This field is hidden when viewing the form
End section (Blank) Mortgage Information Will there be a mortgage?* Will there be a mortgage?
What is the name of the mortgage company? What is the name of the mortgage company?
What is address of the mortgage company? What is address of the mortgage company?
What is the loan number for the mortgage? What is the loan number for the mortgage?
Is there a mortgage?* Is there a mortgage?
What is the name of the mortgage company? What is the name of the mortgage company?
What is address of the mortgage company? What is address of the mortgage company?
Please enter the loan number for the mortgage, if convenient? Please enter the loan number for the mortgage, if convenient?
Is the insurance premium being paid by the bank? Is the insurance premium being paid by the bank?
Additional Insured Is there an additional insured? Is there an additional insured?
What is the name of the additional insured? What is the name of the additional insured?
What is the address of the additional insured? What is the address of the additional insured?
Claim Information Have you had any claims in the past five years? ** Have you had any claims in the past five years? *
Please provide the requested details for all claims from the past five years. Please provide the requested details for all claims from the past five years.
Please describe what was damaged in each claim. Please describe what was damaged in each claim.
Have you filed bankruptcy, lien, repossession, judgement or foreclosure in the last 7 years? ** Have you filed bankruptcy, lien, repossession, judgement or foreclosure in the last 7 years? *
Bankruptcy Information What type of filing did you have in the last 7 years? What type of filing did you have in the last 7 years?
What year did the filing occur? What year did the filing occur?
What year were you charged off as bad debt? What year were you charged off as bad debt?
Documents and Comments Please use this field to upload any relevant insurance documents. (I.e. Current declarations pages, home inspection, etc.) Please use this field to upload any relevant insurance documents. (I.e. Current declarations pages, home inspection, etc.)
Please enter any additional remarks in the space below. Please enter any additional remarks in the space below.
How did you hear about us? How did you hear about us?
Current customer Referred by... Google search Agency's website Email newsletter Facebook Instagram Twitter Other
Please share who referred you to us. Please share who referred you to us.
Please share what you typed into Google. Please share what you typed into Google.
Please share how you heard about us. Please share how you heard about us.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. ** Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
I agree *
