Graham Rogers Manufactured Home Quote Request Form

**If any conviction of fraud, arson or insurance related offenses, OR in foreclosure or 60 days past due on mortgage payment for any property--- Applicant is not eligible.

Is home located in a park of 26 or more spaces? *

yes

Prior Insurance canceled, non-renewed or declined?(except MO) List reas *

Heating Type?

Yes

Personal Property

ACV

RCV

Mailing address same? *

Yes

Has the structure had a previous flood loss? *

Yes

Are there multiple structures on property? *

Yes

Please describe the building for which the quote is being requested. *

Deductible: *

$1000

$2500

$5000

Optional coverages (some coverages may not apply to all programs)

Earthquake

Water Backup

Water Damag

Identity Recovery

Equipment Breakdown

Homeowners: *

Enhanced Coverag

Hobby Farming

Scheduled Personal propert

Discounts & Surcharges: *

Any central, local alarms? LIS

Deadbolts, fire extinguishers & smoke alarm

Is the applicant a member of AAA, USAA or Landlord Association?

Is there an auto policy written for applicant through your agency

Will policy be mortgage billed

Will applicant be paying in full

Will applicant enroll in paperless policy deliver