MOBILE HOMEOWNERS WORKSHEET

First Name: Last Name: Phone Number: Fax Number: E-Mail Address: Age of Oldest Owner:    PROPERTY INFORMATION   Property Address:   Property City: Property State: California Property Zip Code: Purpose Of Use: Owner -Full Time Seasonal (Owner Occupied) Rental Commercial    If Commercial, Indicate Usage: Mobilehome Park Name (If On Private Property Please Indicate): Number Of Spaces In The Park: Year Built: Date You Purchased Your Home: Serial Number: Mobilehome Manufacturer Name: Current Loan Amount $: Is The Mobilehome Tied Down? yes no  Is The Mobilehome Fully Skirted? yes no  Located Within City Limits? yes no  Does The Mobilehome Park Have A Full-Time Resident Manager? yes no  Located On Private Property (Not In A Park)? yes no  Ever Been Refused Insurance In The Last 3 Years? yes no  Located In A Landslide Area? yes no  How Many Stories: 1 2  If Two Stories, Ground Floor Square Footage:   Total Square Footage of Your Dwelling:   Length and Width Of Mobilehome (eg: 24 x 60): Construction Type: Frame Masonry Veneer Masonry Superior   Roof Type: Tile Slate Metal Woodshake Composite Material   Roof Updated: yes no  If Yes, Year Roof was Updated: Protection Distance: 1000 ft or less to a hydrant & 5 mi or less to a fire station Over 1000 ft to a hydrant & 5 mi or less to a fire station Over 5 & up to 10 mi to a fire station Over 10 mi to a fire station  Is Dwelling in the Brush? yes no  Is there a Brush Hazard within (1) mile of Your Dwelling: yes no  If yes, has the Brush been cleared by 250 feet from all sides of Your Dwelling? yesno  Smoke Alarm: yesno Fire Extinguisher: yesno  Deadbolts: yesno Electrical Updated: Yes, Recently Updated No  Circuit Breakers: yes no Copper Wiring: yes no Heating - Air Conditioning, How Old?: Heating - Air Conditioning, Thermostatically Controlled?: yesno  Energy Source:  Gas Electrical  Heating - Air Conditioning, Central? yes no  Does The Mobilehome Have A Woodstove? yes no  Does The Mobilehome Have A Fireplace? yes no  Plumbing Updated: yesno If Yes, Year Plumbing was Updated: Copper Plumbing: yes no  Interior Automatic Fire Sprinklers:  None Partial Full  Theft Alarm: None Local Central  Fire Alarm: None Local  Earthquake Zone: Earthquake Retrofitted:  Not Required, Home Built After 1975 Yes, Bolted or Retrofitted for EQ No   Fire District: Current Insurance Company: Any Dogs on the Property: yes no If Yes, Number & the Breed of Each Dog:   Any Other Pets-Animals on the Property: yes no  If Yes, Number & Description of Each Pet-Animal: Losses-Claims in the last 5 years:  None One Two Three Four Five   If Yes, Date, Amount Paid & Description of Each Loss-Claim      COVERAGE INFORMATION   Dwelling Amount (Coverage A):   Other Structures (Coverage B): Personal Property (Coverage C): Loss of Use (Coverage D): Premise Liability (Coverage E): $25,000 $50,000  $100,000 $300,000 $500,000 $1,000,000  Policy Deductible: 100 250 500 750 1000 2500 5000  If EarthQuake Insurance is Requested, Select Deductible Percentage %: No EarthQuake coverage 10% 15% 20% 25% 30%   Dwelling Replacement Cost Coverage: yesno  Contents Replacement Cost Coverage: yesno Questions or Comments or additional coverages you may need: Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.