Insurance Mobilehome Application

INSURANCE MOBILEHOME APPLICATION

Applicant / Insured Information

Applicant Name:

Mobilehome Information

Owner Name (if different):

Policy Details & Coverage Selection

Select desired policy type (check all that apply):

Optional Coverages & Endorsements

Select additional coverages desired:

Valuation Method (select one): Replacement Cost Actual Cash Value

Exclusions and Important Notices

The policy issued on the basis of this application will contain exclusions and limitations. Common exclusions include, without limitation, loss or damage caused by wear and tear, gradual deterioration, flood (unless specifically endorsed), earthquake (unless specifically endorsed), intentional acts, war, nuclear hazard, and government seizure. Coverage is subject to terms, conditions, limitations, and exclusions contained in the policy issued by the insurer.

Prior Insurance & Loss History

Any losses or claims within the last five (5) years? Yes No

Mortgagee / Lienholder / Payee

Beneficiary Designation

The following designation applies to proceeds payable under the policy to the extent permitted by the policy provisions.

Declarations, Authorizations, and Certifications

I certify that the information provided in this application is true, complete and correctly recorded to the best of my knowledge. I understand that any material misrepresentation, concealment or omission of fact in this application may result in denial of coverage, rescission of the policy, or forfeiture of benefits. I authorize the insurer, its agents and representatives to obtain and exchange information concerning prior insurance, claims history, credit information relevant to underwriting, inspection reports, and other loss-related data for the purpose of underwriting and administering the policy.

I acknowledge that coverage will not be effective until the insurer accepts this application and issues a policy or binder. Any acceptance, binder or coverage provided prior to issuance of a policy is subject to the insurer's underwriting terms and may be conditional upon receipt of premium, completion of inspections, or additional documentation.

I understand that inspection of the mobilehome and its location may be required. I grant permission for the insurer or its designee to inspect the mobilehome, take photographs, and obtain pertinent records to verify the statements made herein.

Fraud Warning: Where allowed by law, intentional misstatements, omissions or fraudulent acts may be subject to civil or criminal penalties, denial of coverage, and recovery of sums paid.

Agent / Broker Information (For company use)

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