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A Service of Simons
Insurance Agency
12743 Bellflower Blvd.
Downey, CA 90242
Toll Free: 888-646-2366
Local Phone: 562-803-3101
Fax: 800-346-2245
satisfaction
Mobilehomeowners Insurance Quotation Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data
Your Name
Property Address
City
State: (Must be California)
Zip Postal
E-Mail (REQUIRED)
Phone
Fax (optional)
Owners Date of Birth?
(Some carriers use birthdates for additional discounts)
Current Home Lender & Loan Amount?
(Some carriers require
for replacement values)
Dwelling Information
Year Home Built:
Home Square footage:
Describe this Modular or Mobile Home: (Year, Make, Model)
Dimensions (Length X Width)
Number of units:
1 family      Duplex
Occupancy Type
Owner occupied
Tenant occupied
Seasonal Dwelling
Vacant or For Sale
(describe in remarks if vacant or for sale.)
% FINISHED
Mobilehome Location
Inside City Limits
Inside park
Inside Subdivision
(describe Park name, or subdivision name below, if any:)
Type Roof:
Shingle
Wood Shake
Tar/Gravel
Metal
Metal      Other
Is mobilehome tied down?
Yes      No
Does mobile home have skirting?
Yes      No
Are there handrails on steps and decks?
Yes      No
Is there a trampoline on premises?
Yes      No
Do you own animals or pets?
Yes      No
If yes, list type/for dogs, list breed:
Do you have a swimming pool?
Yes      No
If yes, list descibe fencing and diving board
Other structures/outbuildings on premesis?
Yes      No
If yes, describe outbuildings and values:
Fire Protection:
# of feet to nearest fire hydrant:
# of miles to nearest
fire station:
Plumbing type:
Copper      Galvanized
Mixed (Copper/Galvanized)
PVC
Circuit Breakers or fuses?
Breakers      Fuses
Heating Type (central thermostat?):
Fireplace or Woodburning Stove? (If yes, describe):
Any business conducted on premises?
(If yes, please describe in detail):
Currently Insured?
Yes      No
Current Carrier and Expiration Date?
Past bankruptcies or reposessions?
(If yes, describe in detail):
Prior Claims?
Yes      No
(If yes, describe claims in detail, and how problems corrected)
# Bedrooms
# Bathrooms
Garage or Carport?
# of cars, attached/detached?
Special features
(i.e., deck, air conditioning, alarm systems, jacuzzi, screened porch, etc.)
Coverages
Dwelling Cov. $
Contents $
Liability Cov. $
Deductible $
($250, $500, $1,000, etc.)
Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here)
Send my quotation via:
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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.
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Simons Insurance Agency
CA License #0772640
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