Insurance Tiny Home Request Form

INSURANCE TINY HOME REQUEST FORM

Use this form to request a new property insurance quote for a tiny home. Complete all sections fully and truthfully. Incomplete or inaccurate information may delay underwriting or result in declination. All answers are representations upon which underwriting decisions will be based.

Applicant / Insured Information

Primary residence: Yes No

Tiny Home Details

Construction type: Wood frame Steel frame SIP Other:

Dimensions: Length: Width: Square footage:

Siting: On permanent foundation On wheels/trailer VIN / Serial #:

Roof type: Insulation (R-value approximate):

Primary heating: Electric Propane Wood stove Other:

Policy Details Requested

Policy type requested: Dwelling Fire Homeowners (HO form) Mobile Home / Manufactured Home Personal Property Only

Coverage limits and amounts: Dwelling limit: $ Contents limit: $

Coverage Options (select all that apply)

Dwelling Personal Property / Contents Personal Liability Additional Living Expenses / Loss of Use

Ordinance or Law (building code upgrade) Theft Vandalism Equipment Breakdown

Special perils often excluded unless endorsed: Flood (separate endorsement required) Earthquake (separate endorsement required)

Note: Flood and earthquake exposures are not provided by standard homeowner or dwelling policies unless specifically quoted and endorsed. Selection here requests a quote only and does not bind coverage.

Exclusions, Duties and Limitations

The following are illustrative, not exhaustive. Standard exclusions include: wear, tear and deterioration; latent defects; insect, vermin, rot, fungus and mold except as otherwise endorsed; flood and earthquake unless endorsed; governmental action; intentional acts by the insured; business or farming operations except as specifically endorsed; loss due to ordinance or law without endorsement. Applicant acknowledges that premium, coverage scope and exclusions will be set by the insurer's underwriting and policy language.

Duty to disclose: Applicant must disclose prior loss history, structural alterations, use for business, and any material facts that affect risk. Failure to disclose material information may void coverage and may subject applicant to civil or criminal penalties.

Safety, Maintenance & Risk Mitigation

Smoke detectors installed and functioning? Yes No

Propane or gas systems professionally installed and inspected within last 2 years? Yes No

Security devices (select all that apply): Deadbolt Alarm Cameras

Beneficiary / Loss Payee

Declaration and Certification

I certify under penalty of law that the statements and answers contained in this request are true, complete and correct to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may result in declination of coverage or rescission of any policy issued based on this request. I authorize the insurer and its representatives to verify any information provided herein, inspect the described property, and obtain loss history as necessary for underwriting. I acknowledge that submission of this form is a request for quotation only and does not bind coverage or alter any insurer's standard policy terms, limits, conditions or exclusions.

Applicant further agrees to maintain the tiny home in a reasonable state of repair and to take all recommended measures to mitigate risk. Coverage, if issued, will be governed by the insurer's policy form and endorsements; this request is not an insurance policy.

Additional Remarks / Clarifications

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