Office 951-301-7303
Cell 951-775-3190

Manufactured Home Insurance

Applicant Name:
Occupation:
Applicant Phone: DOB:
Applicant E-mail:
Risk Address:
Mailing Address:
New Purchase: Y N Prior Carrier: Price:
Occupancy:
In Park:
Park Name:
Lender:
Protection Class (1 - 10):
Losses: Any losses in the Last Three (3) Years? Yes No
If Yes, Explain:
Manufacturer Length Width Year
Dwelling Amount:
Extended Replacement Cost: Yes 125% Yes 120% No Serial No
Golf Cart: Y N Value
Personal Liability:
Personal Property Increase
Other Structures Increase
Flood: Yes No
Animals? Yes No
If yes, what kind:
Deductible:
Wood Burning Stove: Yes No
EQ Earthquake: 10% 15%

Notes