Insurance Application

Insured Type:
Individual Life Estate Trust-Land In Estate Trust-Family
Business Name Trust-Living Other

If individual is selected, complete Individual First Named Insured information. For all others, complete both Individual with Control and Entity that appears on the title or deed.

INSURED TYPE - INDIVIDUAL - Including Tenant

SECOND INSURED

Coverage available in these states: Delaware, Maryland, New Jersey, New York, Pennsylvania and South Carolina

Is home located inside incorporated city limits? Yes No

Is home in park/community? Yes No

Same as location address? Yes No

If NO, provide additional information below.

Does the manufactured home or other structure have a woodstove or fireplace? Yes No

If YES: Factory Installed Commercially Installed Self-installed

1. Have you had any losses within the past 5 years? Yes No

Any theft or liability loss greater than $2,500? Yes No

Any water loss with unrepaired damage? Yes No

Any water related losses greater than $5,000? Yes No

Two or more water losses from same cause? Yes No

Fire loss of any kind? Yes No

Three or more losses of any kind? Yes No

2. Has your policy been cancelled/non-renewed (including non-pay) in the past five years? Yes No

Was the reason non-pay or because the company/agent had withdrawn from product/state? Yes No

3. Have you had 3 or more policies cancel for non-pay in the past 5 years regardless of policy type? Yes No

4. Have you had a lapse of insurance coverage of more than 12 months? Yes No

5. Is the manufactured home raised more than 4 feet on any side? N/A tenant use Yes No

Was it approved by a state, county or local official? Yes No

6. Any farm or ranch activity conducted on the premises, including owning farm animals? Yes No

Does activity meet the Hobby Farm definition? Yes No

If YES, do you want the hobby Farm Endorsement? Yes No

7. Do you own or keep on the premises any non-domestic animal, including any exotic or wild animal? Yes No

8. Do you own or keep on the premises an animal that has caused harm or previously bitten? Yes No

Do you accept the animal liability exclusion? Yes No

9. Is the manufactured home or other structure utilized as a commercial risk or is business conducted on premises, including a day care? Yes No

Is the business incidental? Yes No

10. Is the manufactured home currently vacant, excluding a new purchase that will be occupied in 60 days? Yes No

11. Is the manufactured home fully installed and connected to utilities? Yes No

If NO, will it be fully installed and connected within 60 days? Yes No

12. Does the manufactured home have additions with heat or plumbing? Yes No

Was the addition approved by a state, county or local official? Yes No

13. Do you own any other manufactured home or site built home on the premises? N/A tenant use Yes No

Is it used on a continuous basis for residential living? Yes No

If YES, do you accept the specific structure exclusion? Yes No

14. Are there any other structures 1200 sq. ft. or more with existing damage or in need of repair, excluding cosmetic? N/A tenant use Yes No

15. Is there a pool over 2.5 ft. on the premises? Yes No

Does it meet our fence and gate requirement? Yes No

16. How many miles is home from fire department?