Steve
Stephen B. Groton -- Insurance Agent and Broker
CA License Number 0816642
626-584-6303

Mobile Home & Motorhome
Insurance Quotation Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data:
 
Your Name:
Property Address:
City:
State: MUST be California!
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
1. Information for Mobile Home (If this is a motorhome skip to #2 below)
 
Year Home Built:
Home Square footage:
 
Describe this Modular
or Mobile Home:
(Year, Make, Model)
 
Dimensions
(Length X Width)
 
 
Number of units: 1 family Duplex
 
 
Type foundation: Slab Crawlspace
Pier & Post Other
(list in remarks if raised,
on blocks, tied (or not tied)
down, on dirt, etc.)
 
 
Type Roof: Shingle Wood Shake
Tar/Gravel Spanish Tile
Metal   Other
 
Number of stories: One 1.5
Two Three
 
Do you own animals or pets? Yes No
If yes, list type/for dogs, list breed:
 
Are You Near Brush Area? Yes No
 
# of feet to nearest
fire hydrant: 		# of miles to nearest
fire station:
 
Currently Insured? Yes No
Name of Carrier & how long insured?
 
Prior Claims? Yes No
Describe claims in detail:
 
Plumbing type: Copper Galvanized
Mixed (Copper/Galvanized)
 
Circuit Breakers or fuses? Breakers Fuses
# Bedrooms: # Bathrooms:
 
# Fireplaces: # Chimneys:
 
Special features
(i.e., deck, air conditioning, alarm systems, pool, skirting, attached parking, etc.)
 
Mobilehome Coverages:
 
Dwelling Cov. $ Contents $
Liability Cov. $ Deductible $
($250, $500, $1,000, etc.)
 
 
2. Motorhome Coverages (if motorhome):
 
Year, Make & Model Value $
 
Length of Motorhome Comp/Coll. Deductibles $
 
Liability Cov. $ Driver Ages
(list violations or accidents, if any, in remarks.)
 
Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here. Motorhome coverage, list driving record info.):
 
Send my quotation via: E-Mail Fax
Regular Mail
Call Me By Phone

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