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Mobile
Home Quote Form |
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Please
provide the following information as accurate as possible.
Information provided will not be used for anything other than for the
purpose of this form. |
| Name: |
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| Street
address: |
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| City: |
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| State: |
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| Zip: |
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| Phone: |
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| E-Mail: |
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| Date
of birth: |
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County
in which the
home is located: |
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| Year
built: |
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| Manufactured
by: |
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Dimensions
of
mobile home: |
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Value
of the home
(excluding the land): |
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| Desired
deductible: |
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| Is
the home in a park?: |
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| If
yes, name of park: |
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If
in a park, is it a
senior adult park?: |
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How
many spaces/lots
are in your park?: |
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| Time
in this home: |
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Does
your home have any
NON-FACTORY INSTALLED
wood-stoves or fireplaces?: |
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How
many dogs
do you have?: |
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Have
your dogs previously
bitten anyone?: |
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What
breed of dogs
(either full breed
or mixed): |
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Do
you have any
exotic pets, livestock,
or saddle animals?: |
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If
so, what kind
and how many?: |
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| Is
your home tied down?: |
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Is
the home skirted
or enclosed?: |
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Do
entrances with 3 or
more steps have handrails?: |
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Does
the home have
a trampoline?: |
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Does
the home
have a pool?: |
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Do
porches or decks have
attached railings?: |
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Do
you have any
unattached structures
(sheds, outbuildings,
docks, or garages)?: |
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| If
yes, what kind?: |
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| If
yes, state dimensions: |
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If
yes, state the values of
the structures (empty): |
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Do
you want replacement
cost for your home?: |
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Do
you want replacement
cost for your personal effects?: |
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Will
there be an additional
insured on this property?: |
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Do
you want trip/collision
damage (for 30 days only)?: |
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Is
there a working
smoke/fire detector?: |
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Do
you want coverage
for a golf cart?: |
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| Do you have
insurance now?: |
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| If yes, by which
company?: |
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