Form A4350a0705 - Arizona Mobile Home Application
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1
2CHECK PROGRAM APPLICABLE
Preferred (46)
Vintage (86)
Deluxe (36)
All Purpose (48)
ARIZONA MOBILE HOME APPLICATION
POLICY #: ___________________________
PRINT OR TYPE ALL INFORMATION
APPLICANT/OWNER
(Check box if additional Applicant / Owner is indicated in “Remarks” section on reverse side.)
NAME:
SOCIAL SECURITY NO.:
DATE OF BIRTH
(
)
-
HOME PHONE:
(
)
-
WORK PHONE:
MAILING ADDRESS
CITY
COUNTY
STATE
ZIP
LOCATION ADDRESS (If different than mailing address)
CITY
COUNTY
STATE
ZIP
NAME OF MOBILE HOME PARK
OCCUPATION
EMPLOYER
LIENHOLDER
(Check box if additional Lienholder is indicated in “Remarks” section on reverse side.)
NAME:
ACCOUNT NUMBER:
MAILING ADDRESS:
CITY:
STATE:
ZIP:
PERIOD OF INSURANCE (12:01 A.M. STANDARD TIME)
EFFECTIVE DATE:
NO. OF MONTHS
PREVIOUS CARRIER
FROM:
TO:
DESCRIPTION OF MOBILE HOME/TRAVEL TRAILER
YEAR
MAKE/MODEL
SERIAL NUMBER
LENGTH
WIDTH
DATE PURCHASED PURCHASE PRICE
PHOTOS REQUIRED ON ALL OUT OF PARK OR 1976 AND OLDER UNITS
VALUE
CLASSIFICATION
DESCRIPTION OF ADJACENT STRUCTURES
YES
NO
1.
$
1. How long has insured lived in a mobile home? _______________________
2.
$
2. Is mobile home skirted?
3.
$
3. Woodstove?
(If yes, complete inspection report, #A6000M0493.)
COVERAGES
PREMIUM
TOTAL LIMITS
4. Tied Down?
Mobile Home
Comp.
Named Perils
$
5. Wood
, Masonite
, Vinyl Siding
, Hard Board
?
Adjacent Structures
Comp.
Named Perils
$
6. Check the applicable box(es) of those items in operable condition:
Mobile Home & Adjacent Structures
Comp.
Named Perils
$
Smoke Detector
Fire Extinguisher
Personal Effects
Comp.
Named Perils
$
7. Has insured reported any claim in past 36 months?
Comprehensive Personal Liability
$
Medical Payments
$
8. Has insured reported any claim in past 12 months?
Owner’s, Landlord’s, and Tenant’s Liability
$
9. Does insured/tenant own any dogs or livestock?
$
10. Canceled or nonrenewed in past 36 months?
OPTIONAL COVERAGES:
$
11. Is the mobile home located in an area subject to flood (or on a site which has
$
flooded in the past 10 years), mudslides, brush fires, or high crime?
$
12. Is there a swimming pool, spa, jacuzzi, trampoline or other hazard located on
the premises?
$
$
13. Handrails on all stairways?
$
14. Urethane Roof?
SURCHARGES:
$
15. Does Mobile Home have fuses?
$
16. Does Mobile Home have Polybutelene pipes?
$
#7 - #12, IF YES, EXPLAIN ON REVERSE SIDE
CREDITS:
$
HOW IS MOBILE HOME USED?
$
$
Principle Residence (Owner Occupied)
Rental
P
T
$
Seasonal Residence (Owner Occupied)
Vacant
S
V
$
Commercial (Describe on back)
C
$
Description of Golf Cart (If applicable):
TERRITORY
(From Rate Chart)
PROTECTION CLASS
DEDUCTIBLE(S)
TOTAL PREMIUM
$
$
$
Minimum Written Premium for each policy in the Preferred, Deluxe, and All Purpose Programs: $50.00.
Serial #:
Value: $
Minimum Written Premium for each policy in the Vintage Program: $75.00
BILLING INFORMATION – DIRECT BILL
Minimum Written Premium for each home in the All Purpose Program: $25.00
Minimum Earned Premium for each policy in all Programs, except Vintage when the home is vacant: $50.00
Check Amount Enclosed $ ______________
Minimum Earned Premium for each policy in the Vintage Program for vacant units only: $75.00
LOCATION
DISTANCE OF UNIT TO FIRE HYDRANT: _______________ FEET.
DISTANCE OF UNIT TO FIRE DEPARTMENT: _______________ MILES.
IS MOBILE HOME LOCATED INSIDE CITY LIMITS?
YES
NO
IN MOBILE HOME PARK?
YES
NO
IF YES, NUMBER OF OCCUPIED SPACES: _____________
PAVED STREETS?
LIGHTED STREETS?
FULL TIME RESIDENT MANAGER?
IS MOBILE HOME PARK COMPLETELY FENCED?
YES
NO
ON PRIVATE PROPERTY?
YES
NO
NUMBER OF ACRES: __________ OR MOBILE HOME LOT?
YES
NO
IS THE MOBILE HOME ISOLATED?
YES
NO
IS THE MOBILE HOME EASILY ACCESSIBLE FROM ROAD OR HIGHWAY?
YES
NO
A4350A0705
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