IMPORTANT NOTICE

1. This manufactured home insurance quote request applies only to the states of Oregon and Washington. Do not fill out this form if your manufactured home is not located in Oregon or Washington.

2. No insurance will be started by submitting this form. Coverage may be placed in force only after you decide to purchase it from us, and then after you complete the insurance application and pay the initial premium.

3. Submitting the following quote request constitutes your agreement with the above statements. We will contact you within two business days after we receive your request. If you have ques

Manufactured Home Insurance Quote Request
  1. Your First Name
    Invalid Input
  2. Middle Initial
    Invalid Input
  3. Last Name
    Invalid Input
  4. Date of Birth
    Invalid Input
  5. Social Security Number
    Invalid Input
  6. Phone Number
    Invalid Input
  7. Email Address
    Invalid Input
  8. Name all owners of this property
    Invalid Input
  9. Name residents of the manufactured home
    Invalid Input
  10. Your Street Address
    Invalid Input
  11. City
    Invalid Input
  12. State
    Invalid Input
  13. Zip Code
    Invalid Input
  14. County
    Invalid Input
  15. Address of manufactured home, if different from above
    Invalid Input
  16. Is home inside city limits?
    Invalid Input
  17. Is home in park or community?
    Invalid Input
  18. If 'Yes,' park or community name
    Invalid Input
  19. Mailing address if different from above
    Invalid Input
  20. Type of Woodstove
    Invalid Input
  21. Year home was manufactured
    Invalid Input
  22. Make and Model
    Invalid Input
  23. Width
    Invalid Input
  24. Length
    Invalid Input
  25. Serial or ID Number
    Invalid Input
  26. Is it tied down?
    Invalid Input
  27. Purchase Date
    Invalid Input
  28. Purchase Price
    Invalid Input
  29. Describe any attached additions and values. Do they have heat or plumbing?
    Invalid Input
  30. Amount of coverage wanted
    Invalid Input
  31. Describe any claims or losses in the last 5 years
    Invalid Input
  32. Explain reasons for any insurance cancellations or non-renewals in the last 5 years
    Invalid Input
  33. Is the home raised more than 4 feet on any side?
    Invalid Input
  34. Describe any farm or ranch activity on the premises
    Invalid Input
  35. Describe any pets or animals kept on the premises
    Invalid Input
  36. Have your animals bitten or injured anyone in the last 5 years?
    Invalid Input
  37. Describe any business activity on the premises, including daycare
    Invalid Input
  38. If home is vacant, explain why
    Invalid Input
  39. Is the home fully installed and connected to utilities?
    Invalid Input
  40. Describe any other structures on the premises
    Invalid Input
  41. Describe any swimming pool or area on the premises deeper than 2 feet on the premises
    Invalid Input
  42. Additional information or comments
    Invalid Input
  43. Re-type the security field numbers in the box.
  44. Security Field
    Security Field The Security code you typed did not match. Please click "Refresh" and try again.
  45. To keep a copy of this form, please Print before Submitting
  46.   

Network with BTIA

Follow us on Twitter & Facebook:
BTIA on Facebook  BTIA on Twitter
Share this page with your network:
AddThis Social Bookmark Button

Questions?

If you have questions concerning this information, please call us at 503-620-0230, or come in.

Llámenos ya al 503-620-0230.