Mobile/Manufactured Home
First Named Insured
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
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Second Named Insured (optional)
First Name
Last Name
Date of Birth (second named insured)
-
Month
-
Day
Year
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Phone
Format: (000) 000-0000.
Email Address
example@example.com
Mobile or Manufactured Home Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
In an Approved Park?
Yes
No
Park Name
Is this a modular home? (A Modular Home is built in a factory and transported to a site in modules for installation by a licensed builder)
Yes
No
Other
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dwelling Use
Primary
Landlord / Rental
Secondary / Seasonal
Vacant / Unoccupied
Vacation / Short-term Rental
Primary Farm or Ranch (does not apply to hobby)
Other
Model Year
Width
Length
Wood Stove or Fireplace?
Commercially Installed
Factory Installed
Self Installed
None
Tied Down? (is the home tied down or anchored)
Yes
No
Don't Know
Dwelling Coverage Amount (if known)
Deductible
Please Select
$100
$250
$500
$750
$950
Personal Liability
Please Select
$25,000
$50,000
$100,000
$300,000
$500,000
Other Information
Please Read and Check the Following
*
I understand that coverage cannot be bound or altered in any way by our website, and that this request must be confirmed by an authorized representative of Gallant Risk & Insurance Services.
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