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Main Website: Ken Bleeker.com
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Ken Bleeker Agency, Inc.
Box 145
1617 N Main St.
Martin, MI 49070
Phone: 269-672-5228
Fax: 269-672-5815

E-Mail us at:
myagent@kenbleeker.com

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Mobilehomeowners Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data:
 
Your Name:
Property Address:
City:
State: (Must be Michigan)
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:
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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