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Steve
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
626-584-6303

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

Basic Information:
 
Your Name:
Property Address:
City:
State: MUST be California!
Zip/Postal:
E-Mail (REQUIRED):
Phone (REQUIRED):
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)
 
Dimensions
(Length X Width)
 
 
Number of Units Wide: Single Double Triple
 
 
Type foundation: Pier & Anchor
Slab
Basement
Other
(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!

We respect your privacy! Every step has been taken to insure your privacy and security. It is our intent to release quote information only to you. We will not give your data to ANY other person, company, 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.

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


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