Golden Rule Insurance, Osage Beach, MO

Mobile Home Owners Insurance Quotation Form Your Personal Data:

Your Name:
Property Address:
City:
*State:
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.)

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 basement or boudation?(If yes, describe in comments)	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? (SIf 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 $
($500, $1,000, $2500):

Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here):

Send my quotation via: E-Mail Fax
Regular Mail
Call Me By Phone

Thank you for filling out this form COMPLETELY!
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.

Yes, I Agree. Please Send Me a Quote NOW!
*Golden Rule Insurance is licensed to sell insurance in many states. If you are contacting us from a state in which we are not licensed, we will contact you to inform you that we cannot provide you with a quote.

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Golden Rule Insurance Agency, Inc. - PO Box 810, 4065 Hwy 54, Suite One - Osage Beach, MO 65065 -

Phone# 888-635-4668 or 573-348-1731 - Fax# 573-348-5630 Terms of Use/Privacy Notice -� 2007