Insurance Mobile Home AOR

INSURANCE MOBILE HOME AOR

Applicant / Insured Information

Applicant Name:

Mobile Home / Dwelling Information

Policy Details Requested

Policy Type:

Coverages / Options (Select all that apply)

Available Coverages Dwelling Structure
Personal Property / Contents
Personal Liability
Medical Payments to Others
Loss of Use / Additional Living Expense
Earthquake (optional)
Wind / Hail (if available)

Exclusions and Limitations

The policy provided shall be subject to all standard exclusions, conditions and limitations including, but not limited to, wear and tear, deterioration, intentional acts, loss from neglect, and limits on consequential loss. Applicant acknowledges that specific perils may be excluded unless expressly endorsed.

Claims and Loss History

Within the past five (5) years, has the applicant filed any claims related to the subject mobile home? Yes No

Beneficiary for Proceeds / Payments

Beneficiary Name:

Authorization of Representation / Agent of Record

I, the undersigned Applicant, hereby appoint the Agent named below as my authorized Agent of Record with respect to all insurance matters for the mobile home described above. This appointment authorizes the Agent to:

1. Obtain policy information, premium quotations, policy declarations and endorsements from current or prospective insurers on my behalf;
2. Receive premium notices, policy documents and correspondence related to the policy;
3. Submit applications, bind coverage to the extent allowed by insurer authority, and request endorsements where expressly authorized in writing by me;
4. Communicate with insurers, claims adjusters and third parties for the purpose of administering claims and policy matters.

This appointment is limited and does not constitute authority for the Agent to endorse checks payable to the Applicant, to make settlement decisions without express written authorization from the Applicant, or to change the named beneficiary designation unless specifically permitted below.

Applicant Certification & Authorization

By signing below, I certify under penalty of perjury that the information provided in this form is true, complete and accurate to the best of my knowledge. I authorize any insurer, agent, producer, or their representatives to release policy, claim, and premium information to the Agent designated herein. I understand that this Authorization of Representation remains in effect until I provide written notice of revocation to my current insurer and to the Agent, and that such revocation will not affect actions taken in reliance on this authorization prior to receipt of such notice.

I further acknowledge that appointment of an Agent of Record does not guarantee placement or continuation of insurance coverage; coverage is subject to underwriting approval and acceptance by the insurer. I release the insurer and the Agent from liability for the release of information authorized herein, except for willful misconduct or gross negligence.

Documentation Checklist (Attach as applicable)

Photographs of mobile home and serial plate
Receipts for recent improvements or repairs
Previous policy declarations / loss runs
Police or incident report (if applicable)

Acknowledgment of Electronic Communication

I consent to receive policy documents, notices and communications related to this authorization by electronic means at the email address provided above, unless I specify otherwise in writing. I understand that some communications may require a physical signature and I will be so notified.

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