Form A4350a0705 - Arizona Mobile Home Application (Page 2 of 2) in pdf

CLASSIFICATION RESPONSES

7. DATE OF LOSS: ______________ TYPE OF LOSS: _________________________________________________________________________________________ AMOUNT PAID: $____________________

DATE OF LOSS: ______________ TYPE OF LOSS: _________________________________________________________________________________________ AMOUNT PAID: $____________________

8. DATE OF LOSS: ______________ TYPE OF LOSS: _________________________________________________________________________________________ AMOUNT PAID: $____________________

DATE OF LOSS: ______________ TYPE OF LOSS: _________________________________________________________________________________________ AMOUNT PAID: $____________________

9. DESCRIBE ANIMALS: ___________________________________________________________________________________________________________________________ HOW MANY? _______________

IF DOG, BREED: ____________________________________________________________________________________________________________________ PET OR GUARD DOG? _________________

10. NAME OF COMPANY: _____________________________________________________________________ REASON: _______________________________________________________________________

OTHER REMARKS: _________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

12. IS THERE A FENCE AROUND THE SWIMMING POOL, SPA, JACUZZI, OR TRAMPOLINE MADE OUT OF SUITABLE MATERIAL TO A HEIGHT OF AT LEAST 4½ FEET?

YES

DOES THE FENCE HAVE A SELF-CLOSING GATE?

YES

IS IT AN ABOVE GROUND POOL?

YES

IF YES, VALUE: $ _______________________

USE THIS AREA TO EXPLAIN UNDERWRITING INFORMATION, LIST ADDITIONAL APPLICANTS OR LIENHOLDERS, AND FOR GENERAL COMMENTS OR INSTRUCTIONS.

______________________________________________

IMPORTANT NOTICE: Personal Information about you, including information from a credit or other investigative report, may be collected from persons other than you in

connection with this application for insurance and subsequent amendments and renewals. Such information as well as other personal and privileged information collected

by us or our agent may in certain circumstances be disclosed to third parties without your authorization. Credit scoring information may be used to determine either your

eligibility for insurance or the premium you will be charged. We may use a third party in connection with the development of your score. You have the right to review your

personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information will

be issued with your policy. This notice is given in compliance with the Federal Credit Reporting Act.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance, containing any

materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which i s a

crime and may subject such person to criminal and civil penalties.

SUBAGENT NAME

DATE

APPLICANT SIGNATURE

A4350A0705