Request a quote

NAME INSURED(MUST BE NAMED ON THE TITLE AND RESIDE IN THE HOME) LAST, FIRST MI			DATE OF BIRTH		SOCIAL SECURITY NUMBER
SECOND INSURED (MUST ALSO RESIDE IN THE HOME)
COMPLETE IF A SECOND INSURED IS THE SECOND INSURED A FAMILY MEMBER RELATED TO THE NAMED INSURED? ˜ YES ˜ NO IS TO BE NAMED ON THE POLICY Þ IF NO, IS THE SECOND INSURED ALSO NAMED ON TITLE? (N/A TO TENANT POLICIES . ˜ YES ˜ NO
HOW NAMES SHOULD APPEAR ON DECLARATION PAGE (IF DIFFERENT FROM ABOVE)
ANY INSURED RETIRED? (NJ, NY only) ˜ YES ˜ NO	HOME IN PARK? ˜ YES ˜ NO	HOME LOCATED INSIDE INCORPORATED CITY LIMITS? ˜ YES ˜ NO
PARK NAME LOT NUMBER PARK NUMBER
HOME STREET ADDRESS CITY OR TOWN				STATE		ZIP CODE
COUNTY COUNTY CODE CITY CODE

MOBILE HOME INFORMATION

MODEL YEAR WIDTH LENGTH

DOES THE HOME OR OTHER STRUCTURE HAVE A WOOD BURNING STOVE OR FIREPLACE?

˜ No ˜ Commercially Installed

˜ Factory Installed ˜ Self-Installed (Attack Inspection Form 734960 and Submit to Underwriting)

MOBILE HOME TIED DOWN ˜ YES ˜ NO

DATE OF PURCHASE PURCHASE PRICE$

WHAT IS THE CURRENT VALUE OF THE HOME (EXCLUDING LAND)? $

IS THIS A MODULAR HOME? ˜ UNK ˜ YES ˜ NO

SKIRTED (IF NEEDED TO RATE) ˜ YES ˜ NO

HAIL-RESISTANT SIDING (IF NEEDED TO RATE) ˜ YES ˜ NO

REMARKS

J&B MOBILE HOME SUPPLY
3302 National Parks Hwy.
Carlsbad, New Mexico 88220
(575)885-1900 - - Fax # 575-885-2356

Hours: M-F 8:00am to 5:00pm
Sat: 8:00am to 1:00pm
Lic. #113