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Agent!

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Questions to: craig@southernsecure.com

Local Phone: 205-874-6505
Fax: 205-874-6506

Contact Address:
Southern Secure Insurance
2170 Clearbrook Rd., Suite 208
Birmingham, AL 35226

southern secure insurance agency is an independent brokerage

"Remember, All Our Policies Come With an Agent!"
we guarantee your satisfaction!

Mobilehomeowners Insurance Quotation Form One Simple Form - takes only 2-3 Minutes! Your Personal Data:

Your Name:
Property Address:
City:
State: (Must be Alabama)
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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