First Name:

Last Name:

Phone Number:

Fax Number:

E-Mail Address:

Age of Oldest Owner: 




Property Address:


Property City:

Property State:


Property Zip Code:

Purpose Of Use:


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:

If Two Stories, Ground Floor Square Footage:  

Total Square Footage of Your Dwelling:  

Length and Width Of Mobilehome (eg: 24 x 60):

Construction Type:


Roof Type:


Roof Updated:

yes no 

If Yes, Year Roof was Updated:

Protection Distance:

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?


Smoke Alarm:


Fire Extinguisher:




Electrical Updated:

Circuit Breakers:

yes no

Copper Wiring:

yes no

Heating - Air Conditioning, How Old?:

Heating - Air Conditioning, Thermostatically Controlled?:


Energy Source: 

Heating - Air Conditioning, Central?

yes no 

Does The Mobilehome Have A Woodstove?

yes no 

Does The Mobilehome Have A Fireplace?

yes no 

Plumbing Updated:


If Yes, Year Plumbing was Updated:

Copper Plumbing:

yes no 

Interior Automatic Fire Sprinklers: 

Theft Alarm:

Fire Alarm:

Earthquake Zone:

Earthquake Retrofitted: 


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: 


If Yes, Date, Amount Paid & Description of Each Loss-Claim 





Dwelling Amount (Coverage A):


Other Structures (Coverage B):

Personal Property (Coverage C):

Loss of Use (Coverage D):

Premise Liability (Coverage E):

Policy Deductible:

If EarthQuake Insurance is Requested, Select Deductible Percentage %:


Dwelling Replacement Cost Coverage:


Contents Replacement Cost Coverage:


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.