Name
Phone







6650 Reseda Blvd
Suite #108
Reseda, CA 91335

contact@gisinsure.com
Mobile Homeowners Insruance
 

First Name:
Last Name:
Phone Number:
Fax Number:
E-Mail Address:
Who Referred You To Our Site?

Age of Oldest Owner: 

 

Property Information
 

Property Address:

 

Property City:
Property State:
Property Zip Code:
Purpose Of Use:  
If Commercial, Indicate Usage:
Mobilehome Park Name (If On Private Property Please Indicate):
Number Of Spaces In The Park:
Year Built:
Date You Purchased Your Home:
Serial Number:
Mobilehome Manufacturer Name:
Current Loan Amount $:
Is The Mobilehome Tied Down? yes no  
Is The Mobilehome Fully Skirted? yes no  
Located Within City Limits? yes no  
Does The Mobilehome Park Have A Full-Time Resident Manager? yes no  
Located On Private Property (Not In A Park)? yes  no  
Ever Been Refused Insurance In The Last 3 Years? yes  no  
Located In A Landslide Area? yes  no  
How Many Stories:
If Two Stories, Ground Floor Square Footage:  
Total Square Footage of Your Dwelling:  
Length and Width Of Mobilehome (eg: 24 x 60):
Construction Type:  
Roof Type:  
Roof Updated: yes no  
If Yes, Year Roof was Updated:
Protection Distance:
Is Dwelling in the Brush? yes  no  
Is there a Brush Hazard within (1) mile of Your Dwelling: yes no  
If yes, has the Brush been cleared by 250 feet from all sides of Your Dwelling? yes no  
Smoke Alarm: yes no
Fire Extinguisher: yes no  
Deadbolts: yes no
Electrical Updated:
Circuit Breakers: yes no
Copper Wiring: yes no
Heating - Air Conditioning, How Old?:
Heating - Air Conditioning, Thermostatically Controlled?: yes no 
Energy Source: 
Heating - Air Conditioning, Central? yes no 
Does The Mobilehome Have A Woodstove? yes  no  
Does The Mobilehome Have A Fireplace? yes  no  
Plumbing Updated: yes no
If Yes, Year Plumbing was Updated:
Copper Plumbing: yes no  
Interior Automatic Fire Sprinklers: 
Theft Alarm:
Fire Alarm:
Earthquake Zone:
Earthquake Retrofitted:   
Fire District:
Current Insurance Company:
Any Dogs on the Property: yes no
If Yes, Number & the Breed of Each Dog:  
Any Other Pets-Animals on the Property: yes no  
If Yes, Number & Description of Each Pet-Animal:
Losses-Claims in the last 5 years:   
If Yes, Date, Amount Paid & Description of Each Loss-Claim 

 

Coverage Information
 

Dwelling Amount (Coverage A):

 

Other Structures (Coverage B):
Personal Property (Coverage C):
Loss of Use (Coverage D):
Premise Liability (Coverage E):
Policy Deductible:
If EarthQuake Insurance is Requested, Select Deductible Percentage %:  
Dwelling Replacement Cost Coverage: yes no  
Contents Replacement Cost Coverage: yes no
Questions or Comments
or additional coverages you may need: