Debbie Leek.com - Oregon and Washington Mobilehome and Manufactured home insurance quotes. Fast Online OR and WA Mobilehome Insurance Quotations - free OR and WA Manufactured home insurance quote form.

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We Gladly Accept:

Local Phone:
503-522-8208 (OR)
360-907-2096 (WA)

Fax:
888-458-6784

Mobilehome & Manufacture Home Insurance Quotation Form One Simple Form - takes only 2-3 Minutes! Your Personal Data:

Your Name:
Property Address:
City:
Select State:
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
Primary Insured's Occupation:

Owners Date of Birth? (Some carriers use birthdates for additional discounts)
Current Home Lender & Loan Amount? (Some carriers require for replacement values)

Dwelling Information

Year Home Built:

Mobilehome or Manufactured Home?	Mobilehome Manufactured Home

Home Square footage:

Describe this Modular or Mobile Home: (Year, Make, Model)

Dimensions (Length X Width)

Number of units:	1 family Duplex

Occupancy Type:	Owner occupied Tenant occupied Seasonal Dwelling Vacant or For Sale (describe in remarks if vacant or for sale.)

Mobilehome Location:	Inside City Limits Inside park Inside Subdivision (describe Park name, or subdivision name below, if any:)



Type Roof:	Shingle Wood Shake Tar/Gravel Metal Metal Other

Is mobilehome tied down?	Yes No

Does mobile home have skirting?	Yes No

Are there handrails on steps and decks?	Yes No

Is there a trampoline on premises?	Yes No

Do you own animals or pets?	Yes No

If yes, list type/for dogs, list breed:

Do you have a swimming pool?	Yes No
If yes, list descibe fencing and diving board:

Other structures/outbuildings on premesis?	Yes No
If yes, describe outbuildings and values:

Fire Protection:

# of feet to nearest fire hydrant:	# of miles to nearest fire station:


Plumbing type:	Copper Galvanized Mixed (Copper/Galvanized) PVC

Circuit Breakers or fuses?	Breakers Fuses

Heating Type (central thermostat?):

Fireplace or Woodburning Stove? (If yes, describe):

Any business conducted on premises? (SIf yes, please describe in detail):

Currently Insured?	Yes No

Current Carrier and Expiration Date?

Past bankruptcies or reposessions? (If yes, describe in detail):

Prior Claims?	Yes No
(If yes, describe claims in detail, and how problems corrected):

# Bedrooms: # Bathrooms:

Garage or Carport?: # of cars, attached/detached?

Special features
(i.e., deck, air conditioning, alarm systems, jacuzzi, screened porch, etc.)

Coverages:

Dwelling Cov. $ Contents $

Liability Cov. $ Deductible $
($500, $1,000, $2500):

Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here):

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Debbie Leek Insurance Agency
Oregon Office: 4504 SW Corbett Ave., Suite 100 Portland, OR 97239
Phone: 503-522-8208 (Oregon) | 360-907-2096 (Washington) | Fax: 888-458-6784
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