Insurance and Extended Warranty

Homeowner

Name:
Address:
City:   State:   Zip:
Telephone:   Fax:
Work Phone:   Ext:     E-Mail:
S.S. Number:   Date of Birth (M/D/Y):
Occupation:

Home Info

Park Name and Address or
Location of the Mobile Home: 

Description of the Mobile Home

Year:   Length:   Width:   Serial #:

Manufacturer:   Purchase Price:

Month/Year Purchased:

Adjacent Structures:

List Cabanas, Awnings, Etc. Separately

  
Length Width Description Year/Month Purchased Value

Lien Holder Information

Name:
Address:
City:   State:   Zip:
Loan No.:

Rating Info

Package Line Item

County/Terr: / Owner is a Senior Citizen
Home is Vacant
Trip Collision
$25,000$50,000$100,000 CPL
PE/Replacement Cost
Home Over 10 Years Old
Agreed Value
MH Replacement Cost
Delete Flood Coverage

Adj. Struct: 
PE & PET:  
Sched Prop:

Model Year:
Value:
Primary Use: Owner Occupied Full Time
Seasonal / Rental
Home is Located in a Park
Hardboard Siding
Unit Tied Down
Unit Skirted
Multi-Sectional
Wood Burning Fireplace

Underwritir

Any Business or Farming on the Property?* YesNo
Is There a Swimming Pool on the Premises?* YesNo
Is your manufactured home in an area prone to flooding? YesNo
Any Previous Losses in the Last 3 Years Except Weather Related?* YesNo
Are any Farm or Domestic Animals Kept by the Applicant?* YesNo
Is Dwelling Currently Insured? YesNo

*If Yes, Please Explain in the Appropriate Areas on the Other Info. Tab
 
 Other Info

Loss History - Must List All Losses for the Last 3 Years

Date of Loss Cause Description

Regarding Swimming Pool Fence Enclosure:
Is Fence Completely Around Pool?YesNo  Fence Height:

Regarding Business or Farming on Property

Regarding Farm or Domestic Animals:

Miscellaneous Information: