Le Claire Insurance

J L Le Claire & Sons Insurance Agency

The Protection and Security you would expect from Family

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Mobilehome Quote

MobileHome Insurance Quote Request Complete the following information if you would like to obtain a quote. Please understand this is not an application. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information *Required
*Last Name
*First Name
*Street Address
*City
*State
*Zip Code
Social Security Number
Phone Number
Fax Number
*Email Address
Property Information
*Property Street Address
*City
*State
*Zip Code
*Purpose of Use
If commercial, how is it used?
What is the mobilehome park's name? (if on private property, please indicate)
*What year was your mobilehome built?
*What is the serial number?
*What is the mobilehome manufacturer name?
What is the current loan amount?
*Is the mobilehome tied down?	Yes No
*Is the mobilehome fully skirted?	Yes No
*Is it located within city limits?	Yes No
Does the mobilehome park have a full-time resident manager?	Yes No
Is it located on private property?(not in a park)	Yes No
Have you ever been refused insurance in the last 3 years?	Yes No
*What is the total square footage of the dwelling?
*Length of mobilehome
*Width of mobilehome
What type of roof covering?
Was the roof updated?	Yes No
If yes, what year?
*What is the distance to fire protection?
Is the building in the brush?	Yes No
Is there a brush hazard within one mile of the building?	Yes No
If yes, has the brush been cleared by 250 feet from all sides of the building?	Yes No
Is there a smoke alarm?	Yes No
Is there a fire extinguisher?	Yes No
Are there deadbolts?	Yes No
Is the electrical updated?	Yes No
*If yes, Year electrical was updated
Are there circuit breakers?	Yes No
Does the electrical circuit box have copper wiring?	Yes No
How old is the heating/ air conditioning?
Is the heating / air conditioning thermostatically controlled?	Yes No
What is the heating system?
What is the cooling system?
Has the plumbing been updated?	Yes No
*If yes, Year plumbing was updated
Is the plumbing copper?	Yes No
Does the mobilehome have a woodstove?	Yes No
Does the mobilehome have a fireplace?	Yes No
Does it have interior automatic fire sprinklers?	Yes No
Is there a theft alarm?	Yes No
Is there a fire alarm?	Yes No
*Are there dogs on the property?	Yes No
*If yes, how many and what is the breed of each dog?
*Are there any other pets or animals on the property?	Yes No
*If yes, how many and what is the description of each?
Current Coverage Information
Current Insurance Company
Expiration Date
Current Premium
Were there any losses or claims in the last 5 years?	Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Desired Coverage Information
Dwelling Amount - Coverage A
Other Structures - Coverage B
Personal Property - Coverage C
Loss of Use - Coverage D
Premise Liability - Coverage E
Medical Payments - Coverage F
Policy Deductible
Do you want building replacement cost coverage?	Yes No
Do you want contents replacement cost coverage?	Yes No
Questions or Comments

MobileHome Insurance Quote Request

Personal Information

Property Information

Current Coverage Information

Desired Coverage Information