Manufactured/Mobile Homeowners Quote Request

Manufactured/Mobile Homeowners Quote Request
Insured Information
Named Insured*

First NameMiddle NameLast NameSuffix
Named Insured Date of Birth*

MonthDayYear
Date
Marital Status*

SingleMarriedWidowedDivorcedSeparatedOther
Phone Number*
E-mail*

Confirmation Emailexample@example.com
Will there be an additional named insured?*

YesNo
Additional Named Insured*

First NameMiddle NameLast NameSuffix
Additional Named Insured Date of Birth*

MonthDayYear
Date
Marital Status*

SingleMarriedWidowedDivorcedSeparatedOther
Additional Phone Number
Additional E-mail

Confirmation Emailexample@example.com
Are you okay with us sending text messages regarding your insurance policy and/or quote? By selecting 'Yes' you grant us permission to communicate via text, while maintaining the flexibility to opt out at any time. Rest assured we will not share/sell your information.*

YesNo
Mailing Address*

Street Address or PO Box

Street Address or PO Box Line 2

CityState/Province

Zip CodeCountry
Home Information
Is the address you want a quote on the same as your mailing address?*

YesNo
Address to be Insured*

Street Address

Street Address Line 2

CityState

Zip Code
Year of Construction*
Due to the age of the home, the standard insurance carriers we represent will require a 4-point inspection conducted within the last year that looks at the four major systems (roof, electrical, plumbing and HVAC) of your home and assesses it for risk. You can upload a copy at the bottom of this form to the Browse Files section or email it to main@leereedins.com. Feel free to reach out if you have questions regarding this matter.
Make*
ex., Jacobsen
Model
Length*
In Feet
Width*
In Feet
Is this home a park model?*

YesNo
In order to quote your home, we will need a copy of the home's title as it is essential for us to properly assess your property. You can upload a copy at the bottom of this form to the Browse Files section or email it to main@leereedins.com.
If you happen to have a copy of your home's title available, sharing it with us could make the process of providing you with a quote more efficient and it would be greatly appreciated. You can upload a copy at the bottom of this form to the Browse Files section or email it to main@leereedins.com.
Is this a new purchase?*

YesNo
When did you buy the home?*

0-30 Days31-60 Days61+ DaysJust looking currently
Prior Mailing Address*

Street Address

Street Address Line 2

CityState/Province

Zip Code/Postal CodeCountry
Do you have this home currently insured?*

YesNo
How long has the home been uninsured?*
What is the name of the current carrier?*
When does your coverage expire?*

MonthDayYear
Date
Any losses in the past 5 years?*

YesNo
Has the roof been replaced?*

YesNo
What year was it replaced?*
In order to quote your home, we will need one of the following documents to confirm the age of the roof: a Final Signed off Permit, 4-Point Inspection, Roof Certification, or a Paid Receipt which cannot be handwritten. Any of these documents will suffice and can be uploaded at the bottom of this form to the Browse Files section or emailed to main@leereedins.com.
Type of roof covering*

Asphalt ShingleMetalRubberMembraneOther
Are you in a gated community?*

YesNo
Name of Mobile Home/RV Park*
(if not in a park, indicate Private Property)
Is this your primary FL residence?*

YesNo
Is this a rental property?*

YesNo
How many months out of the year is it occupied??*
Are you a member of AARP or AAA?*

BothAARPAAANeither
Do you have any dogs?*

YesNo
How many and what breed(s)? *
Do you have any farm animals?*

YesNo
How many and what kind(s)? *
Number of Attachments*
ex., shed, carport, screen room, weather-tight room
Attachment #1
Type of Attachment*

ShedCarportScreen RoomWeather-tight RoomOther
Year Built*
Length*
In Feet
Width*
In Feet
Attachment #2
Type of Attachment*

ShedCarportScreen RoomWeather-tight RoomOther
Year Built*
Length*
In Feet
Width*
In Feet
Attachment #3
Type of Attachment*

ShedCarportScreen RoomWeather-tight RoomOther
Year Built*
Length*
In Feet
Width*
In Feet
Attachment #4
Type of Attachment*

ShedCarportScreen RoomWeather-tight RoomOther
Year Built*
Length*
In Feet
Width*
In Feet
Attachment #5
Type of Attachment*

ShedCarportScreen RoomWeather-tight RoomOther
Year Built*
Length*
In Feet
Width*
In Feet
Have you received quotes from any other companies?*

YesNo
Which companies do you have a quote from?*
Do we have permission to pull your consumer credit reports and loss history for insurance purposes? This information is required by certain insurance carriers to provide the most accurate quote possible.*

I grant permission to run my consumer reports.I decline permission to run my consumer reports at this time.
Notes
If you have any documents you think could be useful, feel free to upload them.

Browse Files
Uploads are not required, but are helpful Cancelof
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Manufactured/Mobile Homeowners Quote Request

Insured Information

Home Information

Attachment #1

Attachment #2

Attachment #3

Attachment #4

Attachment #5