Fill - Free fillable Application - Mobile Home Park36-11293 PDF form

MOBILE HOME PARK SUPPLEMENTAL APPLICATION

(Include with ACORD Application)

SIC #: FEIN: Date of application:

Park Name:

Park Location:

Billing Contact Name:

1. Is the park managed by a management company? Yes No

If yes, name of management company:

If yes, % of ownership in the park: %

2. Type of Park: % Retirement % Adult % Family

% Permanent % Seasonal % Other:

3. What is your current rent per space? $ Total number of spaces?

Annual Receipts: $

How often are the rent increases?

What are they based upon?

Occupancy rate: % Tenancy annual turnover rate: %

4. Is there an R.V. overnight exposure? Yes No

If yes, number of spaces:

5. Is there a pool? Yes No

Is there a Jacuzzi? Yes No

Is pool in compliance with all life safety standards? Yes No

Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa

Safety Act?

Yes No

If no, provide time table and action plan:

Comment on the extent of usage:

Is pool fenced with safety rules posted and life saving equipment accessible? Yes No

Is Jacuzzi in same fenced area? Yes No

Is Jacuzzi separate? Yes No

Is there a diving board or slide? Yes No

Explain:

6. Are there any recreational facilities on the park premises such as playgrounds, tennis

courts or golf courses, basketball courts, shuffleboard, bocci courts etc.?

Yes

If yes, describe:

7. Are there any rental units on the premises? Yes No

How many?

8. Do you sell new or used mobile home units? Yes No

How many? Annual Receipts: $

If applicable, are sprinkler pipes running through attic area insulated?

N/A

Yes

Mobile Home Park

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9. Is a log maintained to document all repairs and/or improvements? Yes No

If yes, include a copy.

Do you obtain Certificates of Insurance from all independent contractors? Yes No

Do you obtain hold harmless agreements, in your favor, from independent contractors? Yes No

10. Is there a walk-through inspection of the park for all new residents? Yes No

If yes, include a copy.

11. Does the owner live in the park? Yes No

If no, how often does the owner visit/inspect the park?

Does a full time manager live in the park? Yes No

Are there formal written and enforced park rules? Yes No

If yes, please attach a copy.

12. Is there a well or septic tank on the property? Yes No

If yes, is regular testing and maintenance performed by an outside contractor? Yes No

Written documentation maintained? Yes No

13. Describe park maintenance and housekeeping, including the clubhouse, pool area,

streets and roads:

14. Are underground systems maps available? Yes No

Are the gas lines owned by the park? Yes No

If yes, is the park in compliance with the Federal Pipeline Safety Act (FSPA)? Yes No

If yes, please indicate that compliance documentation will follow and in what form:

15. Has the park experienced a backup of sewage in the past 12 months? Yes No

If yes, please describe what happened and the corrective action taken:

16. Has the park ever been involved in litigation with the residents? Yes No

Does a threat of litigation with the park residents currently exist? Yes No

If yes, please explain:

17. Is security provided? Yes No

Any armed guards? Yes No

Is security totally sub-contracted out? Yes No

18. Does the mobile home park do any hook-ups of mobile homes? Yes No

19.

Are there any operations open to the general public? Yes No

If yes, explain:

20. Are there any plans to reduce services to the park? Yes No

If yes, explain:

21. Have leases been made available to residents? Yes No

If yes, term? Percentage signed? %

Is there an arbitration clause in the lease agreement? Yes No

Does your lease have a pass through for capital improvements and/or increased

operating expenses?

Yes

If yes, have pass throughs ever been included in a rent increase? Yes No

If yes, briefly describe how pass through increase was received by your residents?

Mobile Home Park

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22. Are the park’s fire hydrant outlets 2 1/2 inches? Yes No

Is the responding fire department volunteer? Yes No

If yes explain:

23. Does the park have procedures for fire and medical emergencies? Yes No

24. Are there any major cracks, holes, or uneven areas of sidewalks, parking areas, or

streets?

Yes

If yes, explain action to be taken:

25. Describe park lighting:

26. Is there a swimming or boating exposure on a body of water such as an ocean, lake,

or river?

Yes

If yes, fully describe:

If yes, are no swimming signs posted? Yes No

27. Is the park on leased land? Yes No

If yes, give number of years remaining on lease:

28. Is the park located in a brush, forest, or landslide area? Yes No

If yes, fully describe exposure and applicable protection:

29. Are sporting or social events sponsored? Yes No

If yes, explain:

Describe and include a photo:

30. How often is trash disposed of?

Have you received any complaints about the adequacy of this service? Yes No

If yes, explain remedy:

31. Briefly explain why you feel this park presents a low hazard for becoming involved in

“Failure to Maintain” litigation:

32. For California parks only, regarding park owner disclosure requirement SB 534, has a

Mobile home Park Rental Agreement Disclosure Form been completed?

Yes

If yes, by whom?

Is the completed form on file and available to prospective tenants?

Yes No

Attach a copy of the completed disclosure form to this questionnaire.

33. Do you have a current Flood policy in force? Yes No

If yes, attach a copy of the Declarations sheet.

If no, would you like a Flood quote with our Proposal? Yes No

(Flood quote will be secured through the Write Your Own Flood Program)

Mobile Home Park

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FRAUD STATEMENT AND SIGNATURE SECTIONS

The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief

and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true

and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes

prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the

quote or binder.

The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.

*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company

VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,

MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN

EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.

FRAUD NOTICE STATEMENTS

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 IS A CRIME AND SUBJECTS THAT PERSON TO

CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY

BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS

($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,

NM, OK, PA, RI, TN, VA, VT, WA AND WV).

APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR

FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN

APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.

APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN

INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE

IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO

KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE

OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM

INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY

AGENCIES.

APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER

FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A

FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).

APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE

PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER

OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION

OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR

PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR

COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT

MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.

APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS

FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF

MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING

INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,

FINES OR A DENIAL OF INSURANCE BENEFITS.

APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON

FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE

PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A

CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON

FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE

PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A

CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH

SUCH VIOLATION.

NAME (PLEASE PRINT/TYPE) TITLE

(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE

DIRECTOR)

_______

______________________________________________________

SIGNATURE DATE

SEC

TION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT

PRODUCER AGENCY

(If this is a Florida Risk, Producer means Florida Licensed Agent)

PRODUCER LICENSE NUMBER

(If this a Florida Risk, Producer means Florida Licensed Agent)

ADDRESS (STREET, CITY, STATE, ZIP)

Mobile Home Park

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CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL

QUESTIONNAIRE

Name of Applicant:

Address of Applicant:

City: State: Zip:

Website: www:

Nature of Operations:

1. Annual sales or revenue: $

2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)

belonging to customers, clients, or other third parties, other than employees?

If yes, please indicate the types of Personally Identifiable Information held (check all that apply):

Yes No

a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or

other State Identification Numbers

b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)

c. Credit or Debit Card Information

3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for

damage to their computer system(s) arising out of the operation of the Applicant’s computer

system(s)?

Yes No

b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a

lawsuit agains

t the Applicant all

eging invasion or interference of rights of privacy or the

inappropriate disclosure of Personally Identifiable Information (PII)?

Yes No

c. During the last three (3) years, has the Applicant been the subject of an investigation or

action by any regulatory or administrative agency for privacy-related violations?

Yes No

d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a

claim being made against them for the coverage being applied for?

Yes No

PI-CYBE-APP (11/16)

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FRAUD STATEMENT AND SIGNATURE SECTIONS

The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge

and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this

Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information

in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the

Company may modify or withdraw the quote or binder.

The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.

*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company

FRAUD NOTICE STATEMENTS

ANY PERSON W

HO 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 IS A CRIME AND SUBJECTS THAT PERSON TO

CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY

BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS

($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,

NM, OK, RI, TN, VA, VT, WA AND WV).