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Vacant Dwelling

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Mobile/Manufactured Home

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Manufactured Home

Note: If LLC, Estate or Trust, Named Insured 1 information is required

Please review ALL your answers for accuracy as many required drop-down options are pre-selected. Incorrect or placeholder answers will only lengthen the processing time.

Insured Information

Desired Effective Date *

LLC, Estate or Trust Name (if applicable)

Named Insured (1)

First Name *

Last Name *

Named Insured (2)

First Name

Last Name

Location Address

Street *

City *

State Of *

ZIP / Postal Code *

Mailing Address

Street *

City *

State / Province *

ZIP / Postal Code *

Contact Info.

Primary Phone Number *

Alternate Phone

E-Mail Address *

Date of Birth Named Insured (1) *

Social Security # Named Insured (1) *

Date of Birth Named Insured (2)

Occupations Named Insured (1) *

Occupations Named Insured (2)

Marital Status *

Current Insurance Information

Current/Prior Insurance Carrier *

Current Insurance in-force? *

Policy Expiration Date

Is above Policy being Cancelled by Current Carrier? *

If so, Reason & Cancellation Date? (If none type none) *

Claims/Property Losses in Last 5 Years? *

If Claims, Please list and explain

Dwelling Information

Year Purchased *

Purchase Price *

# of bedrooms *

#of full bathrooms *

#of half bathrooms *

Do You Own The Land? *

Located In a Park? *

If Yes, Name of Park

Is Home Skirted? *

Is Home Occupied *

Year Manufactured *

Make and Model *

Serial Number *

Width & Length *

Square Footage *

Heat Type *

If Oil, where is the tank?

Miles to Fire Department *

Distance to Hydrant *

Deck *

Deck Square Footage

Pool *

Pool Features *

Trampoline *

Smoke Detectors *

Fire Extinguishers *

Central Station Burglar Alarm *

Central Station Fire Alarm *

If so, how are they operated?

Pets *

If Pets, What Kind *

If Pets, How many *

If Pets, Breed

If Pets, Bite history *

Valuable Items Requiring Special Coverage

Number Of Items

Total Value

Agency/Agent Information

Agency Name *

Agency Number *

Agent Email Address *

Additonal Information/Notes

IMPORTANT NOTICE
Please note that after your submission we will contact you with a price indication but it is ultimately up to the carrier to accept or reject each risk. All price indication are reliant upon the information you as the agent have provided to United Agency Alliance, L.L.C

Price indications will be subject to the carrier underwriting guidelines and final approval. The carriers may obtain various underwriting reports which may include but not limited to C.L.U.E., credit and/or carrier specific reports.

Any submissions made via this website do not constitute a binding agreement to a policy or coverages. Changes to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Resources

Headquarters

56 Payne Road
Lebanon, NJ 08833
P: 973.526.7038