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Stephen B. Groton -- Insurance Agent and Broker
110 South Rosemead Blvd Suite F
Pasadena, CA 91107
Across Rosemead Blvd from the Pasadena DMV.

CA License Number 0816642

Mobile & Manufactured Home
Insurance Quotation Form
One Simple Form - takes only 2-3 Minutes!

Basic Information:
Your Name:
Property Address:
State: MUST be California!
Fax (optional):
1. Information for Mobile Home (If this is a motorhome skip to #2 below)
Year Home Built:
Home Square footage:
Describe this Manufactured Home:
(Make and Model)
(Length X Width)
Number of Units Wide: Single Double Triple
Type foundation: Pier & Anchor
(list in remarks if tied down
or not, skirted or not)
Type Roof: Shingle Metal
Wood Shake Composite Metal
Other (specify in remarks)
Do you own animals or pets? Yes No
If yes, list type/for dogs, list breed:
Are You Near Brush Area? Yes No
# of feet to nearest
fire hydrant:
# of miles to nearest
fire station:
Currently Insured? Yes No
Name of Carrier & how long insured?
Prior Claims? Yes No
Describe claims in detail:
Plumbing type: Plastic Copper
Circuit Breakers or fuses? Breakers Fuses
# Bedrooms: # Bathrooms:
# Fireplaces: # Chimneys:
Special features
(i.e., deck, air conditioning, alarm systems, pool, skirting, attached parking, etc.)
Mobilehome Coverages:
Dwelling Cov. $ Contents $
Liability Cov. $ Deductible $
($250, $500, $1,000, etc.)

Thank you for filling out this form COMPLETELY!

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Yes, I Agree. Please Send Me a Quote NOW!

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