Home Office: One Nationwide Plaza • Columbus, Ohio 43215
Administrative Office: 8877 North Gainey Center Drive • Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
Mobile Home Parks and Campgrounds Program Supplemental Application
(Complete in addition to ACORD General Liability Application)
Name of Applicant:
_________________________________________________________________________________________________________
1. Operation:
θ
θ
θ
Permanent Park
RV Park
Campground
2. Number of spaces:
Number of permanent spaces:
_________________________________________________________________________________________
Number of tourist (RV and Camping) spaces:
__________________________________________________________________________
Number of permanent or tourist spaces containing your units rented to others:
________________________________________
Year of construction of the oldest rental unit (NY only):
________________________________________________________________
3. Operating season:
From
to
______________________
_____________________
4. Other operations:
θ
θ
Parks
Tennis/Racquetball/Volleyball/Basketball Courts
and Baseball Diamonds
Number of acres:
_______________________________
θ
Number:
________________________________________
Playgrounds
θ
Bathing Beaches
Number:
________________________________________
θ
Number:
________________________________________
Restaurants/Lounges
θ
Bicycle Trails
Number:
________________________________________
Number of trail miles:
___________________________
Total sales: $
____________________________________
θ
θ
Boats
Saddle Animals for Hire
Number:
________________________________________
Number:
________________________________________
Type:
___________________________________________
(describe):
______________________________________
θ
θ
Boat Docks/Slips
Saunas
Number:
________________________________________
Number:________________________________
θ
θ
Club House including any exercise room
Security Guards
Square footage:
________________________________
Number employed:
______________________________
θ
Convenience Store
Number of independent guards:
_________________
θ
θ
Number:
________________________________________
armed
unarmed
θ
Total sales: $
___________________________________
Shooting Ranges
θ
Horse Trails
Number:
________________________________________
Number of trail miles:
___________________________
Type (bow, shotgun, etc.):
_______________________
θ
θ
Lakes
Spas/Hot Tubs
θ
Lake formed by a Dam (complete GLS-113)
Number:
________________________________________
Number of acres:
_______________________________
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GLS-APP-38s (3-02)