R.R.I.S. MOBILE HOME PARK QUOTE REQUEST                 

        Please provide the following contact information:

 (The Referral Agent is the name of your Insurance Agent in our office or how you became aware of our website)

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
FEIN #
Work Phone
FAX
E-mail
URL

        Please provide quotes for :

General Liability       Workers Compensation    Commercial Automobile   Commercial Property   
License Bond            Performance Bond        Course of Construction  Life                  
Group Medical           

        General Liability Limit Requested (choose one):

$100,000 $300,000 $500,000 $1,000,000 occurrence/$1,000,000 aggregate $1,000,000 occurrence/$2,000,000 aggregate

        Please describe your operations:

        What is the name of your current insurance carrier?

        What is your current expiration date? :

        Please describe any claims you have had in the past 5 years with date of loss:

            RV Spaces  annual gross receipts / Number of RV Spaces?

Mobile Home Gross Receipts / Number of spaces?

        How many employees do you have?

        What is your estimated payroll over the next 12 months?

        How many years have you been in business?

        How many years at this location?

        Describe Recreational Facilities (playground, swimming pool, spa, pond, lake, etc.):

Do you have a convenience store here? If so, please provide:

Annual Grocery Sales
Annual Liquore Sales
 

        Use this for addional explanation area: