Personal Information |
First Name
Required
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Last Name
Required
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Street
Required
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City
Required
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State
Required
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ZIP / Postal Code
Required
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Primary Phone Number
Required
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E-Mail Address
Required
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Is this a new purchase?
Required
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How long residing at present location?
Required
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If less than 3 years, list prior address.
Optional
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Insured Person #1 Information |
Full Name
Required
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Gender
Required
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Marital Status
Required
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Date of Birth
Required
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Social Security Number
Optional
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Insured Person #2 Information |
Full Name
Optional
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Gender
Optional
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Marital Status
Optional
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Date of Birth
Optional
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Social Security Number
Optional
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Current Information |
Are you currently insured?
Required
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If yes, who is the current carrier?
Optional
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If you are currently insured, what was the prior amount at which the mobile home was insured?
Optional
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Mobile Home Information |
Mobile Home Use
Required
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Year
Required
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Make
Required
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Model
Required
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Length
Required
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Width
Required
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Located in mobile home park?
Required
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If yes, what is the name of the mobile home park?
Optional
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Located on private property?
Required
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How many acres?
Required
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Do any farming activities take place on the premises?
Required
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County where mobile home is located?
Required
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Is it underpinned?
Required
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Is it tied down?
Required
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Is it on a permanent foundation?
Required
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What type of roof?
Required
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Heat Type
Required
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Central air conditioning?
Required
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Wood burning stove?
Required
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Garage/ Car Port?
Required
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Garage/Car Port Size
Optional
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Any other structures on property? If so, describe.
Optional
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Swimming pool?
Required
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If there is a swimming pool, is it enclosed with a fence and a locked gate?
Optional
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If there is a swimming pool, does it have an elevated diving board (more than 1 step)?
Optional
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Trampoline?
Required
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If yes, is the trampoline enclosed in a fence, locked gate, and surrounding net?
Optional
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Are there any pets with bite history or any exotic, undomesticated, or vicious animals on the premises?
Required
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Any dogs?
Required
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If yes, is the dog one of the following breeds: Rottweiler, Doberman, Pit Bull (all variants), Akita, Husky/Malamute, Chow, German Shepherd, Presa Canarios, or Great Dane?
Optional
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Are there any business pursuits being conducted on the premises?
Required
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Smoke detectors?
Required
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What kind of alarm do you have?
Required
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Is mobile home located 5 miles or less from the primary responding fire department?
Required
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Who is the primary responding fire department?
Optional
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Is mobile home within 1,000 feet of a fire hydrant?
Required
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Any losses or claims in the last 5 years?
Required
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If yes, please list the date and a brief explanation of each claim or loss.
Optional
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Submission Validation Required |
Enter the Validation Code from above.
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