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    E-Mail:
    glamb@farmersagent.com

    Local Phone:
    281-537-2700

    Website Design by:
    Insurance-Web-Sales © 2006

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    Manafactured and Mobilehomeowners Insurance Quotation Form
    One Simple Form - takes only 2-3 Minutes!
    Your Personal Data:
     
    Your Name:
    Property Address:
    City:
    State: MUST be Texas!
    Zip/Postal:
    E-Mail (REQUIRED):
    Phone:
    Fax (optional):
     
    Owners Date of Birth?
    (Some carriers use birthdates for additional discounts)
     
    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:)
     
     
     
    Is the mobilehome tied down? Yes No
     
    Does mobile home have skirting? Yes No
     
    Do you own a dog? Yes No
     
    If yes, list type/for dogs, list breed:
     
    Fire Protection:  
     
    # of feet to nearest
    fire hydrant:     		# of miles to nearest
    fire station:
     
     
    Circuit Breakers or fuses? Breakers Fuses
     
    Fireplace or Woodburning Stove? (If yes, describe):
     
    Any business conducted on premises?
    (If yes, please describe in detail):
     
     
     
    Prior Claims? Yes No
    (If yes, describe claims in detail, and how problems corrected):

     
    Coverages:
     
    Dwelling Cov. $ Contents $
    Liability Cov. $ Deductible $
    ($500, $1,000, $2500):
     
     
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    Lamb Insurance Agency   |  28 FM 1960 West, Houston, TX 77090
    Phone: 281-537-2700   Fax: 281-537-8502   Cell: 281-881-5756