Manufacturered Home Insurance Inquiry Form
Pennsylvania Only
Insured Name 1:
     Social Security #:   Birth Date: 
Insured Name 2:
     Social Security #:   Birth Date: 
Mailing Address:
City:
    State:    Zipcode: 
Phone (home, work, cell):
E-Mail Address:
Location of Unit:
 Address:
  County:    Mobile Home Park: Yes / No      If Yes, number of spaces in park:
Current Insurance Company:         Expiration Date:

Coverages
Unit Year    Make/Model:    Length:    Width:     Use: 

Mobile/Manufacturered Home Value Contents Value Unattached Structures Value Personal Liability Limit Medical Payments
per Person
$ $ $ $ $
Property Deductible Purchase Date Purchase Price Feet from a Fire Hydrant Miles to the
nearest Fire Department
$

General Questions.......
Where is the mobile/manufactured home parked?
Is there a swimming pool? Yes       No
Do you own or board any German Shepherd, Doberman, Pit Bull, Chow, Akita, Rottweiler, Great Dane, Wolf hybrid, or any mix of these breeds or any pet known to be unfriendly or any dog that has bitten or any guard dog or do you own or board horses or livestock or any other large or unusual /exotic animals? Yes       No
Is the manufactured home equipped with a supplemental heating source?
      If Yes, what is it? 		 Yes       No
Is any business conducted on the premises? Yes       No
Is there a kerosene heater on the premises? Yes       No
Is the manufactured home vacant, unoccupied or without utilities? Yes       No


Home Page
E-Mail
M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway            Murrysville, PA. 15668-1890
(724) 327-8474                  (FAX) 327-7911
Toll Free: 1-800-977-2999     (FAX) 1-888-800-0034