On-Line Mobile Home Insurance Quote Form Complete our Minnesota mobile home insurance information form and we will be in touch soon. Personal Information Enter your full name: Mailing Address: City: County: State: Zip Code: Email: Email (again for accuracy): Phone: Owners Date of Birth & Social Security #:(Some carriers use for additional discounts) Dwelling Information Year home built: Describe this Modular or Mobile Home:(Year, Make, Model) Dimensions (Length X Width) No. of units:---1 familyDuplex Occupancy Type:---Owner occupiedTenant occupiedSeasonal DwellingVacant or For Sale (describe in remarks if vacant or for sale.) Mobile in a park? (If so, please list name) Type Roof:---Fiberglass ShingleWood ShakeTar/GravelAsphalt ShingleMetalOther (list in remarks) Is mobile home tied down?---YesNo Does mobile home have skirting?---YesNo Are there handrails on steps and decks?---YesNo Do you own animal or pets (if yes, list type/for dogs, list breed)? Do you own trampoline?YesNo Do you have a swimming pool?---YesNo If yes, list describe fencing and diving board: Other structures/outbuildings on premises?---YesNo If yes, describe outbuildings and values: Fire Protection: # of feet to nearest fire hydrant: # of miles to nearest fire station: Fireplace or Wood Burning Stove? (If yes, describe): Currently Insured? (If yes, list carrier, and # of years continuous. If none, type NONE): Name of carrier & how long insured: Prior Claims?---YesNo Describe claims in detail: Special features (i.e. deck, air conditioning, alarm systems, pool, etc.): Home Coverages: Dwelling Coverage: $ Content: $ Liability Coverage: $ Deductible ($500, $1,000, $2,500, etc.): Comments/Remarks (describe any scheduled jewelry, guns, furs & collectibles, in-home business, boats, ATV, snowmobile, or other special coverages/remarks here) Send my insurance quotation via :EmailFaxRegular MailCall me by phone Thank you for filling out this form completely.We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. Yes, I agree. Please send me a mobile home insurance quote now.