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Applicant Full Name
City, State, Zipcode
Business Phone Number
Home Phone Number
Mobile Home Year Make Model
Is the mobile home tied down? Yes No
Is the mobile home skirted? Yes No
Are there any room additions added to this home? Yes No
Are you in a mobile home park of more than 26 mobile homes? Yes No
Is mobile home located on more than one acre? Yes No
Is your mobile home presently insured? Yes No
If yes, Insurance Company:
What is the current market value?
What is replacement cost?
Have you had ANY loss within the last three years? Yes No
If yes, please list losses:
Date Type of Loss Amount Paid By Ins. Co.
Do you have replacement coverage on your home? Yes No
Do you have replacement coverage on your personal contents? Yes No
What are your liability limits?
What is your deductible?