Manufactured Homeowners Insurance Application - Southern Family Insurance

Manufactured Homeowners Insurance Application

Step 1 of 8

12%

Proposed Effective Date?*
Prior Insurance Company
Prior Insurance Expiration Date
Dwelling Coverage Amount (Policy Coverage A)

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Personal Information
How Did You Hear About Us?
Name*
First Last
Date of Birth*
SSN (Last 4)
Drivers License Number
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone
Work Phone
Email*

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Location Information
Occupancy Info*
Year Built*
Manufacture Name
Home Location*
Lot Size*
Name of Park or Subdivsion*
If Appicable, Name Of Mortgage Co
Is Insurance Escrowed?*

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Roof Material*
Roof Type*
Roof Updated*
Roof Updated Date
Electrical Updated*
Electrical Updated Date
Plumbing Updated*
Plumbing Updated Date
Heating & Cooling Updated*
Heating & Cooling Updated Date
Heating & Cooling Source

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Monitored Burglar or Fire Alarm*
Monitored Burglar or Fire Alarm Professionally Installed*
Fire Place*
Garage / Carport*
Length x Width
Skirting*
Porches Or Decks*
Window/Door Awnings*
Utility Shed*
Room Additions*
Pool?*
Pool Screen / Fence
Pool Diving Board?
Guard / Gated*
Flood Zone*
Within 1000 ft of Fire Hydrant*
Within 5 Miles of Fire Station*

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Pets
Pets*
How Many Pets?
Please enter a number greater than or equal to 1.
Pet Type / Breed
Bite History?
Bite History Details

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Claim(s) in Three Years?*
How Many Claims?
Please enter a number greater than or equal to 1.
Claim Details
Bankruptcy In Seven Years?*
Notes

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* Social Security Number is required by most companies in order to review consumer reports such as ownership, prior coverage proof, claims history and credit rating. The underwriters we use do use credit history to provide you with the most appropriate rate.
If you choose not to have your consumer reports reviewed please check this box
I Decline

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