NEWS Insurance Services Inc.

Mobile Home Application Form

1501 Westcliff Dr. Suite 301
Newport Beach, CA. 92660
Tel: (877) 700- NEWS
Fax: (949) 554-0250
Email: Info@newsinsurance.com
Web: www.newsinsurance.com

MOBILE HOME QUESTIONAIRE

* Mandatory fields

Quote Date:
Full Name :	*
Location :	*
City :	*
State :	Zip Code :
Phone Number :	- *
Cell Phone Number :	-
Business Number :	- Ext. :
Current Policy Date:	- - Expiry Date : - -
Social Security Number :
E-Mail :	*

Mailing Address if same as above .
And if not please type it in here :

DWELLING TYPE : (please provide the construction type of your Home)

Year Built : *	Square Footage : *	Is this your Residence
Has your home ever Renovated? : Yes No
If "YES", please check the choices that apply :
Plumbing	Year renovated :
Roofing	Year renovated :
Electric	Year renovated :
Heating	Year renovated :
Build Type :	Building Condition :
Occupancy Type : Construction Quality :	Structure Type :
Roof Material : *	Condition of Roof :
If "other" please specify :
How May Fireplaces do you have?

HOME SECURITY

- -

Is your Home a gated Community?		Does your Home have fire Sprinklers?
Is your home privately gated?		What type of Security System ?
Do you have a Swimming Pool? *
If "YES" check the ones that apply:
Approved Fence	Diving Board
Above Ground	In-Ground
Slide

PRIOR COVERAGE

Who was your prior insurance provider?	Have you had any losses in the past 3 yrs.?
What was your prior Policy No.?	If so, what type of claim did you have?
	If so, what was the amount? $

GENERAL INFORMATION

Is you building undergoing renovation or reconstruction?
If so, what is the total completed value & date of completion?

Do you own any Recreational Vehicles ? (Snow mobile, Dune Buggy, Mini Bikes etc.)
Do you have coverage Declined, Cancelled or Non-Renewed
Do you have any Live-in employee(s)?
Do you have any Animals or Exotic Pets kept on premises?
Coverage
Building Limits : $ Personal Property : $ Liability :
Separate Structure : $ Umbrella :

SCHEDULED PERSONAL PROPERTY

	Write a brief description	Total Value
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
* For BLANKET COVERAGE, please specify total dollar amount of all items combined

Additional Comments :

Sales Agent: