Mobile/ Manufactured Home Supplemental Application		We would like to provide you with a free, no-obligation Mobile/ Manufactured Home insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

(Serving Washington, Oregon, and Idaho)

Personal Information Name: Mailing Address: City:     State: Washington Oregon Idaho     Zip: Physical Address: City:     State: Washington Oregon Idaho     Zip: Telephone #:     Fax #: E-Mail Address: Your Date Of Birth:   Description Of Home Year:     Manufacturer (Make): Length:     Width: Check Any That Apply: Woodstove     Pelletstove Fireplace          Fireplace Insert Current Insurance Company: Usage Of Home: Primary Home Secondary Home Rental Home The Home Is Located: In A Park     On Private Land VIN Number:   Purchase Price: $ The Home Is On: A Continuous Foundation     Blocks and Skirting Type Of Skirting:   Type Of Roof: Mortgage/Loss Payee: Address: Loan #: Description Of All Owned Animals:   Claims and Miscellaneous Info List All Claims Against Homeowners In Past Five Years: Description Of Any Detached Structures On Your Home (I.E.: Garage, Shop, Carport, Etc.) Include Size And Value: Description Of Any Attached Structures On Your Home (I.E.: Deck, Garage, Carport, Etc.) Include Size And Value: Do You Require Any Scheduled Personal Property On This Policy For Jewelry, Guns, Furs, Antiques, Etc.? YES   NO   If Yes, Please Describe: Is The Home Located In A Known Flood Area? YES   NO   Description Of Home What Limits Of Insurance Does Your Current Policy Extend? Dwelling: $ Personal Property: $ Other Structures: $ Loss Of Use: $ Personal Liability: $ What Is Your Current Deductible?: $ Your Current Premium?: $ Earthquake Included? YES   NO Flood Included? YES   NO How Did You Hear About Us? Please let us know how you found out about our agency on the internet: Search Engine    (Type:)   Please Select One AltaVista AOL Search Excite Google HotBot Lycos MSN Search Northern Light Webcrawler Yahoo OTHER Direct Mail     Yellow Pages     Already a Customer     Referral    (By:)   Other    (Type:)       Submit Information Click Submit and a representative from Petra Insurance will contact you by: E-mail   Regular Mail      Phone   Best time to call?  Morning Afternoon Evening Fax   Fax Number: