Strickland General Agency, Inc                                                                        Mobile Home Quick Quote (Georgia)

* Signifies a REQUIRED Field

* Agency #:    E-mail Address:

* Agency Name:

* Insured Name:    * DOB (mm/dd/yyyy):

* MFG Year:    * MH Value:    * Program Type:    PE Amount:   

* Protection Class:    City Limits:Yes    No    * County:    Date Purchased (mm/yyyy):

Prior Coverage on this Property:Yes    No    Expiration date of prior Coverage (mm/yyyy):

In Park:Yes    No    If Yes, # Spaces:    * Leinholder:Yes    No    * Length:    * Width:    * Deductible:    Liability:

MH Replacement Cost:Yes    No    PE Replacement Cost:Yes    No    Secured Interest Protection:Yes    No    Med Pay:

Flood (flood coverage not available in Zone A of NFIP or if flood occurred within past 10 years:Yes    No    Earth Movement:Yes    No   

Questions or Comments: