MANUFACTURED

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INSURANCE QUESTIONNAIRE

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Insured Information

Name

Age

Mailing Address

Address (cont.)

City

State

Zip/Postal Code

Physical location of property

(if other than mailing)

Phone

FAX (Optional)

Return E-mail (Optional)

Please contact me via:

Year of Manufacture

Mobile Home Make

(Manufacturer) / Model

Measurements

(Length X Width e.g. 70 x 14)

Woodstove or Fireplace? Yes No

Mobile Home Value $

Within 5 miles of fire station? Yes No

Type of occupancy

Any dogs or exotic pets? Yes No

If so, please indicate breed of dog or name of exotic pets

:

# of losses in past 5 years:

Within 1000' of tidal water

(i.e. ocean, bay, river, creek, etc.)
Yes No

Agent Requested

Comments:

Mailing Address
Address (cont.)
City
State
Zip/Postal Code
Physical location of property (if other than mailing)
Phone
FAX (Optional)
Return E-mail (Optional)
Please contact me via:

Year of Manufacture
Mobile Home Make (Manufacturer) / Model
Measurements (Length X Width e.g. 70 x 14)
Woodstove or Fireplace?	Yes No
Mobile Home Value $
Within 5 miles of fire station?	Yes No
Type of occupancy
Any dogs or exotic pets?	Yes No
	If so, please indicate breed of dog or name of exotic pets :
# of losses in past 5 years:
Within 1000' of tidal water (i.e. ocean, bay, river, creek, etc.)	Yes No

Agent Requested
Comments:

MANUFACTURED

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INSURANCE QUESTIONNAIRE

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