Manufactured Home Quote Request Form All States

Agent Information

Agency Name

Agent Name

First Last

Agent Phone

Agent Email

Customer Information

Requested Effective Date*

I am interested in Flood coverage for this customer

Yes

Customer Name*

First Last

Customer Date of Birth*

Social Security Number

Phone

Email

Does the applicant intend to enroll in paperless policy delivery?

Yes
No

Will the applicant be paying in full?

Yes
No

Location Address

Street Address Address Line 2 City State ZIP Code

Is Mailing Address the same as the location address

Yes
No

Mailing Address

Street Address Address Line 2 City State ZIP Code

Will there be a Co-Applicant?

Yes
No

Co-Applicant Name

First Last

Co-Applicant Date of Birth

Social Security Number

Phone

Email

PLEASE READ TO CUSTOMER

In connection with this quote for insurance, the individual insurance companies may review your credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. They may use this information to decide whether to insure you or how much to charge. They may use a third party in connection with the development of your credit score.

In connection with this application for insurance, the individual insurance companies may review your claims history or loss experience and may report future claims made by you to a claims history provider.

By submitting this form you accept that some carriers will run credit on the insured and have informed the insured of this.

Home Details

Country (Location)

Country

Date Purchased:

Purchase Price: $

Year of Home:

Make:

Model:

Length of Home

Width of Home

Serial Number:

In a park?

Yes
No

How many space in park?

Exp. Date of Current/Previous Policy:

Protection Class:

Miles from Fire Station:

Feet to Nearest Fire Hydrant:

Animals on the premises?

Yes
No

Please describe:

How is home occupied?

Is there any private, not-for-profit farming on premises?

Yes
No

Has the applicant been convicted of arson, fraud, or other insurance-related offenses?

Yes
No

Is the applicant in foreclosure or currently 60 days or more past due on mortgage payments for any property?

Yes
No

Has the applicant moved in the last 60 days?

Yes
No

If yes, provide previous address

Eligible for multi-policy discount?

Yes
No

Does the applicant currently have an automobile policy written through your agency?

Yes
No

Is the applicant a member of any of the following organizations?

AAA
Landlord Association (Any)
USAA
No

Membership Number

Does the home have Vinyl or Hardboard Siding?

Yes
No

Is the home skirted?

Yes
No

Is the home tied down?

Yes
No

Does the home have a composite roof?

Yes
No

Is the home vacant or unoccupied?

Yes
No

Is there a swimming pool on the premises?

Yes
No

Have there been any claims in the last 5 years?

Yes
No

*If Yes, please list details (Dates, Type, Dollar Amounts):

Has the applicant had similar insurance declined, cancelled, or non-renewed?

Prior Loss History
Payment Problems
Physical Hazard or Condition
Carrier No Longer Writes in State
Carrier No Longer Writes this Type of Business
Applicant No Longer Belongs to Association or Group
No
Other

Will the dwelling be occasionally rented to others?

Yes
No

How many months is the unit rented to others?

For the length of time the applicant has owned the dwelling, how many days has it gone uninsured?

Is dwelling under construction or major renovation?

Yes
No

Supplemental heating source?

None
Masonry Fireplace
Wood Burning Stove
Other

If other, what heating source was it?

Foundation Type:

Foundation Shape:

Rectangular
L-Shape
Other:

If other, what is the foundation shape?

Attached Garage—# of Stalls:

Special Details for Replacement Cost Estimator (e.g. Attached Garage, Additions)

Is the risk a modular home?

Yes
No

Inside city limits?

Yes
No

Is the land owned by the client?

Yes
No

Previous policy expiration:

Coverage

Home (Coverage A)

Requested $ Limits

Personal Property

Requested $ Limits

Unattached Structures

Requested $ Limits

Liability (Personal/Premises)

Medical Payments

Requested $ Limits

All Peril Deductible

Requested $ Limits

Wind and Hail Deductible

Requested $ Limits

Golf Cart Coverage

Scheduled Personal Property

Yes
No

Scheduled Personal Property Items

Categories	Amount

Secondary Residence Liability

Yes
No

Water Back Up (American Modern only)

Yes
No

Full Repair Cost

Yes
No

Replacement Cost - Home

Yes
No

Replacement Cost - Personal Property

Yes
No

Equipment Breakdown (American Modern only)

Yes
No

Hobby Farming

Yes
No

Earthquake (Available in all states)

Yes
No

Mine Subsidence (Available in IN, IL, OH)

Yes
No

Exclusions

Animal Liability Exclusion

Yes
No

Specific building Exclusion

Yes
No

List the buildings to be excluded:

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Manufactured Home
Quote Request Form
All States

Agent Information

Customer Information

PLEASE READ TO CUSTOMER

Home Details

Coverage

Exclusions

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Grand General Agency – contact information
1240 Chicago Dr
Jenison, MI 49428
Phone (800)869-2022
Fax (888)767-0826
Text Line: 616-606-FAST(3278)