Name: Deerfield Advisors Insurance Agency
Address: 16225 Park Ten Place, Houston, TX, 77084, US
Telephone: (281) 550-5864

General Information Section
First Name (Primary)
Last Name
Date of Birth
Occupation
First Name (Secondary/Spouse)
Last Name
Date of Birth
Occupation
Home Phone
Mobile Phone
Work Phone
Email Address
Physical Address
Please indicate your preferred method of communication:
- Voice/Phone
- Email
- Fax
- Text
Manufactured Home Section
MANUFACTURED HOME DEFINED:

Please note that the insurance carrier considers a Manufactured Home that is used as a single family residence to be sitting on a permanent slab foundation bolted down with posts assembled onsite in sections piece by piece. This is for clarification and to avoid confusing Manufactured Homes with Double Wide Mobile Homes which are built on a trailer frame and then just attached together.
Manufactured Home Use
- Primary
- Primary Farm/Ranch (Applies to Primary use risks when Farm/Ranch operations exceed our Hobby Farm Definition)
- Secondary
- Tenant (Renter's personal property & liability) NOTE: Insurance on the home can be placed through our Rental Manufactured Home Program.
DOES THE FIRST NAMED INSURED RESIDE IN THE HOME?
- Yes
- No
IS THE SECOND NAMED INSURED A RESIDENT FAMILY MEMBER OF THE FIRST NAMED INSURED?
- Yes
- No
If NO, does the second insured have an insurable interest and reside in the home?
- Yes
- No
Insured Type - All Others N/A Tenant
ENTITY THAT APPEARS ON THE TITLE OR DEED:
First Individual with Control
LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH
Second Individual with Control
LAST NAME FIRST NAME MIDDLE INITIAL
Manufactured Home Location Address
HOME LOCATED INSIDE INCORPORATED CITY LIMITS?
- Yes
- No
IS HOME IN PARK/COMMUNITY?
- Yes
- No
PARK/COMMUNITY NAME LOT NO.
Manufactured Home Location Address (Street, City, Zip )
Manufactured Home Information
DOES THE MANUFACTURED HOME OR OTHER STRUCTURE HAVE A WOODSTOVE OR FIREPLACE?
- No
- Factory Installed
- Commercially Installed
- Self-Intalled
Manufactured Home Information
Model Year Width Length Make/Model Serial No.
MANUFACTURED HOME TIED DOWN?
- Yes
- No
DATE OF PURCHASE
PURCHASE PRICE
COVERAGE AMOUNT: (Include attached additions but exclude land value.)
IS THIS A MODULAR HOME?
- Yes
- No
Underwriting Questions
Has the applicant had any losses in the past 5 years?
- Yes
- No
If YES, provide loss information
Any theft or liability loss greater than $2,500? Any water loss with unrepaired damage?
- Yes
- No
Any water related losses greater than $5,000?
- Yes
- No
Two or more water losses from same cause?
- Yes
- No
Fire loss of any kind?
- Yes
- No
Three or more losses of any kind?
- Yes
- No
Has the applicant’s policy been canceled/non-renewed (including non-pay) in the past 5 years?
- Yes
- No
Was the reason non-pay or because the company/agent had withdrawn from product/state?
- Yes
- No
Has the applicant had 3 or more policies cancel for non-pay in the past 5 years regardless of policy type?
- Yes
- No
Has the applicant had a lapse in insurance coverage of more than 12 months?
- Yes
- No
Please list the name of the policy that lapsed & give the reason for the lapse.
Is the manufactured home raised more than 4 feet on any side? N/A tenant use?
- Yes
- No
Was it approved by a state, county or local official?
- Yes
- No
Any farm or ranch activity conducted on the premises, including owning farm animals?
- Yes
- No
If YES, provide loss information
Does activity meet the Hobby Farm definition?
- Yes
- No
If yes, do you want the Hobby Farm Endorsement? (Only available when liability is added)
- Yes
- No
Does the applicant own or keep on the premises any non-domestic animal, including any exotic or wild animal?
- Yes
- No
Describe animal.
Does the applicant own or keep on the premises an animal that has caused harm or previously bitten?
- Yes
- No
Is the manufactured home or adjacent structure utilized as a commercial risk or is business conducted on premises, including day care? If YES, and tenant use, risk is unacceptable.
- Yes
- No
Is the business incidental?
- Yes
- No
Is the manufactured home currently vacant, excluding a new purchase that will be occupied within 60 days?
- Yes
- No
NOTE: If the manufactured home risk is unacceptable due to vacancy
- Yes
- No
Is the manufactured home fully installed and connected to utilities?
- Yes
- No
If NO, will it be fully installed and connected within 60 days? NOTE: Requires Trip Coverage. N/A tenant use
- Yes
- No
Does the manufactured home have additions with heat or plumbing?
- Yes
- No
Was the addition approved by a state, county or local official?
- Yes
- No
Is any other structure a manufactured home, site built home, farm building or larger than 1200 sq. ft.?
- Yes
- No
If YES and structure is insured with another company, list here and notate policy.
If YES and structure is not insured with another company, submit with photos and describe how structure is used.
Is there a pool over 2.5 ft. on the premises?
- Yes
- No
Does it meet our fence and gate requirements?
- Yes
- No
Signature*
Name*

Save and Continue Later

Manufactured Home Insurance Questionnaire

General Information Section

Manufactured Home Section

Insured Type - All Others N/A Tenant

Manufactured Home Location Address

Manufactured Home Information

Underwriting Questions

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