To receive an accurate quote, please fill out the following form as completely as possible, making sure to enter your phone number(s) correctly below.  We will review your request and call you with a quote within one or two business days. If you prefer, you may print out this form and fax it to us at (352) 728-3996.       

Fields marked with *are required.  Note that additional fields may be required as indicated depending on the answers to certain questions.  When you are finished filling out the form, please click the "Submit" button at the bottom of the page.

Contact Information
  
*First name MI *Last name
*Home phone () -
Other phone () -
When is the best time to contact you?
  
Current mailing address
  
Address 1
Address 2
City State ZIP
Location of address to be insured
  
*Address 1
Address 2
*City *State *ZIP
What park is the home located in?
 
How did you hear about us?
  
If you are just buying the home, when is your closing date?
  
If you already own the home, when does your present insurance expire?
(MM/DD/YYYY)		  
If you already own the home and you are looking for new insurance, what company are you currently with?
  
*Whose name is the home titled in?
  
*Who is living in the home?
  
*What is the year of the home?
(YYYY)		  
*What is the make?
  
*What is the size? (length x width in feet)
x (length x width in feet)		  
What is the serial number?
  
*Do you have a loan on the home?
Yes No 		 
If yes, what is the name of the lender?
  
If you have or will have a loan, is the loan escrow?
Yes No 		 
*How many months out of the year do you live in the home?
  
If you live in the home less than 12 months out of the year, do you rent out the home at any time?
Yes No 		 
If you rent the home out, how many months out of the year do you rent it?
  
*What is the first owner's occupation?
  
*What is the first owner's date of birth?
(MM/DD/YYYY)
What is the second owner's occupation?
  
What is the second owner's date of birth?
(MM/DD/YYYY)
*Is there any business (including Avon sales, childcare, etc) conducted on the premises?
Yes No 		 
If there is any business conducted, please describe:
  
*Do you own a boat?
Yes No 		 
If yes, do you need coverage?
Yes No 		 
*Do you own a golf cart?
Yes No 		 
If yes, do you need coverage?
Yes No 		 
If you need coverage on the cart, please provide year of cart:
(YYYY)		  
Make of cart:
  
Value of cart:
$		  
*Are there any animals on your property?
Yes No 		 
If yes, how many and what breeds?
  
Any history of biting?
Yes No 		 
*Is there a swimming pool?
Yes No 		 
*Is there a trampoline?
Yes No 		 
*Do you own the land where the home is located?
Yes No 		 
*Do you need any floaters for scheduled property such as: jewelry, furs, cameras and related equipment, golf equipment, postage stamps, coins, firearms, fine arts, musical instruments, silverware?
Yes No 		 
If yes, please tell us which items and a total value for each category:
  
*Have you filed any claims within the last five years?
Yes No 		 
If yes, provide description(s) and date(s) and amount(s) paid out:
*Do you have central heat?
Yes No
Carport Attachment
*Do you have a carport attached to the home?
Yes No
If yes, what size?
x (length x width in feet)
Approximately what year was the carport added? (If unknown, please make approximate guess)
(YYYY)
Screen Porch Attachment
*Do you have a screen porch (without windows) attached to the home?
Yes No
If yes, what size?
x (length x width in feet)
Approximately what year was the screen porch added? (If unknown, please make approximate guess)
(YYYY)
Enclosed Porch Attachment
*Do you have an enclosed porch (with windows) attached to the home?
Yes No
If yes, what size?
x (length x width in feet)
Approximately what year was the enclosed porch added? (If unknown, please make approximate guess)
(YYYY)
Other Attachments
*Do you have a utility shed, laundry room, or golf cart shed attached to the home?
Yes No
If yes, what size?
x (length x width in feet)
Approximately what year was the shed added? (If unknown, please make approximate guess)
(YYYY)
Please list any other attached additions in the areas below:
Description Length Width Aprox. Year Added
Description Length Width Aprox. Year Added
Description Length Width Aprox. Year Added
Built Ins and Other
*Do you have a roof with shingles?
Yes No
*Do you have a fireplace or woodstove?
Yes No
*What type of skirting do you have?  (Aluminum, brick, vinyl, or other?)
*Do you have smoke alarms?
Yes No
*Do any residents smoke?
Unattached Structures
Do you have any structures that are not attached to the home? This means structures set apart from the home by a clear space such as a shed out in the back yard, a boat dock, etc.  If so, please list them below.
Description Length Width Value $
Description Length Width Value $
Description Length Width Value $
Valuation
*What amount do you want to insure the home for?  (do not include land)
$
If you have any comments or notes for us, please provide them in the area below:

Copyright © 2006 Ammerman Insurance Agency