Insurance Score / Claim History Disclosure
 
 
 
In connection with this application for insurance, we may review your credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of your insurance score. In connection with this application for insurance, we may review your claims history or loss experience and may report future claims made by you to a claims history provider. 
 
 
 
Applicant agrees to these terms. **
 
 
 
 
 
 
 
Mobile Home Quote Request
 
 
 
 
Once you complete and submit this form, an agent will contact you within five business days to provide your quote. For an immediate quote, call 1-866-884-6167 Mon - Fri 8 - 8 ET.

All fields marked with an asterisk are required. For some of the coverage-specific questionsbelow, you may find it useful to have your current policy or declarations page handy.
  
First Name*
 
 
 
 
Last Name*
 
 
 
 
Email*
 
 
 
 
If you do not have an email address, please give us a call at 866-880-8651. 
 
 
 
Date of Birth (mm/dd/yyyy):*
 
 
 
 
Address*
 
 
 
 
City*
 
 
 
 
State*
 
 
 
 
Zip Code:*
 
 
 
 
How did you hear about us?*
 
 
 
 
If Agent, who is the agent?
 
 
 
 
 
 
 
Home Information
 
Is the home located at a different location than the mailing address you provided above? *
 
Yes
No
 
 
 
If you answered Yes, it is important that you provide the Address, City, State and Zip:
 
 
 
 
How is the home used?*
 
 
 
 
What amount of coverage do you want on your home? This dollar amount is the amount you wish to receive in the event your home is totally destroyed. When answering this question, you may want to think about your home's current value and what it would take to replace it.*
 
 
 
 
Model Year:*
 
 
 
 
Length (in feet):*
 
 
 
 
Width*
 
 
 
 
In what year did you purchase the home?*
 
 
 
 
Does the home have a wood burning stove or fireplace that was professionally installed?
 
Yes
No
 
 
 
Is the home located on land that you own?*
 
Yes
No
 
 
 
How many miles away is the closest fire department?*
 
 
 
 
Is your home inside or outside city limits?*
 
Inside city limits
Outside city limits
 
 
 
Does the home have a composite shingle roof?*
 
Yes
No
 
 
 
Does the home have protective siding?
 
Yes
No
 
 
 
Are you the original owner? *
 
Yes
No
 
 
 
Is the home currently insured?*
 
 
 
 
If yes, who is your current insurance company?
 
 
 
 
What date do you want your coverage to take effect (mm/dd/yyyy)?*
 
 
 
 
 
 
 
Please provide the following information so we can contact you with your quote.
We respect your privacy and will never sell or rent your contact information to third parties.
 
 
 
 
 
 
How would you prefer that we contact you?*
 
 
 
 
Daytime Phone Number
 
 
 
 
Alternate Phone Number
 
 
 
 
 
 
 
Best Time to Contact
 
 
 
 
 
 
 
American Modern may periodically email you news and information related to specialty insurance products.
 
 
 
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