This form is intended for the use of Texas residents only.
Use "Tab" to move from field to field

Use:
Policy Term: yrs.
Effective Date:

 


Named Insured (Must be named on the title and reside in the home)
Date of Birth Social Security Number

 


E-Mail Address (Required)

Day Phone
Evening Phone
Fax Number

How would you prefer that we reply to you?

Mobile Home Location

Mobile home in park? Mobile home located inside incorporated city limits?
Park Name: Lot No. Park No.

Street Address
City , TX Zip Code
County: County Code: City Code:

Mobile Home Information

Model Year: Width: Length:
Make/Model:
Serial Number:
Does the mobile home have a woodburning stove or fireplace?
Mobile home tied down?
Date of purchase: Purchase Price:
What is the current value of the mobile home (excluding land)?
Amount of Personal Effects coverage desired:
Skirted? Hail resistant siding?
Is the home located within 1500' of any river or creek or any coastal or tidal water?
Is the home located on a site that has been previously flooded?
Is the home raised more than 4 feet on poles, pilings, or blocks?
If yes, was it raised to comply with a state or local requirement? Type "yes" or "no"
Does the home have non-professionally-built attached additions (includes two different mobile homes joined together; does NOT include open porches, decks, and carports)?
If yes, was a building permit secured at the time of construction? Type "yes" or "no"
If there was no building permit issued, was the work inspected by an authorized building inspector at time of completion? Type "yes" or "no"
Is there an unattached structure on the premises that :
a) is a mobile home, site built house, farm building, or
b) is used as primary living quarters, or
c) is larger than 1200 squre feet?
Does the applicant have any animals or exotic pets?
If yes, specify what kind and how many:
Has the applicant had a lapse in insurance coverage for more than 12 months?
Has any applicant had a fire, theft, or liability loss of more than $2500 and/or 2 or more fire, theft, or liability losses (any amount) during the past 3 years?
Does any applicant conduct a business (including day/child care) on premises?
Has any applicant had dwelling coverage cancelled or nonrenewed for underwriting reasons (claim frequency, uncorrected hazard, etc.) during the past 3 years?

 

In the space provided below, please feel free to add any comments or details that you feel are relevant.

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This web page is designed to allow the general public in the state of Texas to request quotations, and related information. The quotations that are returned to the requester are NOT binding policies; they do not guarantee insurability nor coverage upon receipt of quotation. The agent must have a signature and money to bind a policy. For exact numbers, definitions, or coverages of any terms discussed, please contact Tom Sorrels Mobile Home Insurance Agency.