DISCLAIMER:
Evidence of Insurance/Binders can only be bound by a licensed agent.
Binders must be paid within 10 Days.

Quotes/Binders can be issued in the following states:
Alabama, Arizona, Arkansas, California, Colorado, Idaho, Illinois, Kentucky, Lousiana, Michigan, Mississipi, Montana, Nevada, New Mexico, New York, Oregon, Texas, Utah, Washington, & Wyoming

For "QUOTE ONLY", please fill out form down to and including the question regarding earthquake coverage.

For "BINDER REQUEST", please fill out form completely.
 
Name
Email Address
Phone#
Zip Code
Year of Home
Length
Width
Use of Unit
Location of Home
Purchase Price or Required Amount
Date of Birth
Add Earthquake Coverage?
   
For "BINDER REQUEST", please fill out form completely
   
Additional Coverage
Property Address
Social Security Number
Marital Status
If Applicable, Name of the Park
Effective Date
Manufacturer
Serial Number
Lien Holder Name
Requesting Company
Requested By
Company Phone
Company Fax
Comments/Escrow Information
Submitted By
   
 
Manufactured Housing Insurance Services #0D80824
1500 East Katella Avenue, Suite One, Orange, California 92867
Toll Free: 866-644-7111 Toll Free Fax:866-628-1033
E-Mail: customerservice@mhis.info