MOBILE HOME APPLICATION FORM MOBILE HOME QUESTIONAIRE Fields marked (*) are mandatory.   Quote Date * Choose MonthJanuary February March April May June July August September October November December Choose Date  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Choose Year  2006 2007 First Name * Last Name * Location * City * State * Zip Code * Phone Number * - Cell Phone Number - Business Number - Ext. : Current Policy Date Expiry Date : Social Security Number E-Mail * Mailing Address if same as above & if      not please type it in here :   DWELLING TYPE : (please provide the construction type of your Home) Fields marked (*) are mandatory.   Year Built * Square Footage* Is this your Residence? --Select-- Primary Secondary Seasonal Has your home ever Renovated? Yes No If "YES", please check the choices that apply : Plumbing Year renovated : Roofing Year renovated : Electric Year renovated : Heating Year renovated : Build Type -- Select -- Frame Masonry Masonry Veneer Fire Resistive Building Condition -- Select -- Excellent Good Fair Poor Occupancy Type -- Select -- Owner Tenant Vacant Construction Quality -- Select -- Average Luxury Custom Structure Type -- Select -- Dwelling Townhouse Apartment Condominium Roof Material * -- Select -- Tile Wood Shingles Ceramic Other Condition of Roof -- Select -- Excellent Good Fair Poor If "other" please specify How May Fireplaces do you have? -- Select -- 0 1 2 3 4 5+   HOME SECURITY Fields marked (*) are mandatory.   Is your Home a gated Community? Yes No Is your home privately gated? Yes No Does your Home have fire Sprinklers? Yes No What type of Security System ? None Local & Fire Central & Fire Central & Burglary Local & Fire & Burglary Central & Fire & Burglary Do you have a Swimming Pool? * Yes No If "YES" check the ones that apply: Approved Fence Diving Board Above Ground In-Ground Slide     PRIOR COVERAGE Who was your prior insurance provider? What was your prior Policy No.? Have you had any losses in the past 3 yrs.? Yes No If so, what type of claim did you have? If so, what was the amount? $   GENERAL INFORMATION Is you building undergoing renovation or reconstruction? Yes No If so, what is the total completed value & date of completion? Do you own any Recreational Vehicles ? (Snow mobile, Dune Buggy, Mini Bikes etc.) Yes No Do you have coverage Declined, Cancelled or Non-Renewed Yes No Do you have any Live-in employee(s)? Yes No Do you have any Animals or Exotic Pets kept on premises? Yes No Coverage   Building Limits $ Personal Property $ Liability - - Value - - 300,000 500,000 1,000,000 Separate Structure $ Umbrella $1,000,000 $3,000,000 $5,000,000 $10,000,000 $20,000,000 $50,000,000 $100,000,000   GENERAL INFORMATION     Write a brief description Total Value ITEM 1 CAMERAS COINS FINE ARTS FURS GOLFER'S INSTRUMENTS JEWELRY MUSICAL INSTRUMENTS PERSONAL COMPUTER SILVERWARES STAMPS OTHER COLLECTABLES # OF PIECES BLANKET 1 2 3 4 5 6 7 8 9 10+ $ ITEM 2 CAMERAS COINS FINE ARTS FURS GOLFER'S INSTRUMENTS JEWELRY MUSICAL INSTRUMENTS PERSONAL COMPUTER SILVERWARES STAMPS OTHER COLLECTABLES # OF PIECES BLANKET 1 2 3 4 5 6 7 8 9 10+ $ ITEM 3 CAMERAS COINS FINE ARTS FURS GOLFER'S INSTRUMENTS JEWELRY MUSICAL INSTRUMENTS PERSONAL COMPUTER SILVERWARES STAMPS OTHER COLLECTABLES # OF PIECES BLANKET 1 2 3 4 5 6 7 8 9 10+ $ ITEM 4 CAMERAS COINS FINE ARTS FURS GOLFER'S INSTRUMENTS JEWELRY MUSICAL INSTRUMENTS PERSONAL COMPUTER SILVERWARES STAMPS OTHER COLLECTABLES # OF PIECES BLANKET 1 2 3 4 5 6 7 8 9 10+ $ ITEM 5 CAMERAS COINS FINE ARTS FURS GOLFER'S INSTRUMENTS JEWELRY MUSICAL INSTRUMENTS PERSONAL COMPUTER SILVERWARES STAMPS OTHER COLLECTABLES # OF PIECES BLANKET 1 2 3 4 5 6 7 8 9 10+ $ ITEM 6 CAMERAS COINS FINE ARTS FURS GOLFER'S INSTRUMENTS JEWELRY MUSICAL INSTRUMENTS PERSONAL COMPUTER SILVERWARES STAMPS OTHER COLLECTABLES # OF PIECES BLANKET 1 2 3 4 5 6 7 8 9 10+ $ ITEM 7 CAMERAS COINS FINE ARTS FURS GOLFER'S INSTRUMENTS JEWELRY MUSICAL INSTRUMENTS PERSONAL COMPUTER SILVERWARES STAMPS OTHER COLLECTABLES # OF PIECES BLANKET 1 2 3 4 5 6 7 8 9 10+ $ ITEM 8 CAMERAS COINS FINE ARTS FURS GOLFER'S INSTRUMENTS JEWELRY MUSICAL INSTRUMENTS PERSONAL COMPUTER SILVERWARES STAMPS OTHER COLLECTABLES # OF PIECES BLANKET 1 2 3 4 5 6 7 8 9 10+ $ ITEM 9 CAMERAS COINS FINE ARTS FURS GOLFER'S INSTRUMENTS JEWELRY MUSICAL INSTRUMENTS PERSONAL COMPUTER SILVERWARES STAMPS OTHER COLLECTABLES # OF PIECES BLANKET 1 2 3 4 5 6 7 8 9 10+ $ ITEM 10 CAMERAS COINS FINE ARTS FURS GOLFER'S INSTRUMENTS JEWELRY MUSICAL INSTRUMENTS PERSONAL COMPUTER SILVERWARES STAMPS OTHER COLLECTABLES # OF PIECES BLANKET 1 2 3 4 5 6 7 8 9 10+ $ * For BLANKET COVERAGE, please specify total dollar amount of all items combined Additional Comments Sales Agent Do you have coverage Declined, Cancelled or Non-Renewed Yes No   Thank You for Completing Our Online Quote! Click Submit to Send

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