DESCRIPTION OF ADJACENT STRUCTURES
VALUE
1. $
2. $
3. $
COVERAGES
TOTAL LIMITS PREMIUM
Mobile Home o Comp. o Named Perils $
Adjacent Structures o Comp. o Named Perils $
Mobile Home & Adjacent Structures o Comp. o Named Perils $
Personal Effects o Comp. o Named Perils $
Comprehensive Personal Liability $
Medical Payments $
Owner’s, Landlord’s, and Tenant’s Liability $
$
OPTIONAL COVERAGES: $
$
$
$
$
$
SURCHARGES: $
$
$
CREDITS: $
$
$
MISCELLANEOUS FEES: $
$
$
TERRITORY (From Rate Chart) PROTECTION CLASS DEDUCTIBLE(S) TOTAL PREMIUM
$ $ $
CHECK PROGRAM APPLICABLE
o Preferred (46) o Vintage (86)
o Deluxe (36) o All Purpose (48)
POLICY #: ____________________________________
G.A. #: SUBAGENT #
APPLICANT/OWNER o
(Check box if additional Applicant/Owner is indicated in “Remarks” section on reverse side.)
NAME: SOCIAL SECURITY NO.: 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: DATE OF BIRTH: OCCUPATION: EMPLOYER:
LIENHOLDER o
(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:
FROM: TO:
NO. OF MONTHS PREVIOUS CARRIER
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
LOCATION
DISTANCE OF UNIT TO FIRE HYDRANT: _______________ FEET. DISTANCE OF UNIT TO FIRE DEPARTMENT: _______________ MILES.
IS MOBILE HOME LOCATED INSIDE CITY LIMITS? o YES o NO IN MOBILE HOME PARK? o YES o NO IF YES, NUMBER OF OCCUPIED SPACES: _____________
o PAVED STREETS? o LIGHTED STREETS? o FULL TIME RESIDENT MANAGER? IS MOBILE HOME PARK COMPLETELY FENCED? o YES o NO
ON PRIVATE PROPERTY? o YES o NO NUMBER OF ACRES: __________ OR MOBILE HOME LOT? o YES o NO
APPLICATION MUST BE COMPLETED IN FULL, INCLUDING REVERSE.
AP
CLASSIFICATION
1. How long has insured lived in a mobile home? ______________ YES NO
2. Is mobile home skirted? o o
3. Tied Down? o o
4. Wood, Masonite, or Vinyl Siding? o o
5. Does the Mobile Home have a Supplemental Heating device?
(If yes, complete inspection report, #A6000M0586 (R4/93).)
o o
6. Does the applicant own any dog of a protective nature including but
not limited to: Pit Bull, Rottweiler, Doberman, Akitas, Wolf Hybrid, or
any dog with a previous history of biting?
o o
7. Does insured/tenant own any livestock? o o
8. Has insured reported any claim in past 36 months? o o
9. Canceled or nonrenewed in past 36 months? o o
10. Is the mobile home isolated from easily accessible public roadways? o o
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?
o o
12. Is there a swimming pool, or other hazard located on the premises? o o
13. Handrails on all stairways? o o
14. Does the Mobile Home have fuses? o o
#5 - #12, IF YES, EXPLAIN ON REVERSE SIDE
HOW IS MOBILE HOME USED?
o Principle Residence (Owner Occupied) P
o Rental T
o Seasonal Residence (Owner Occupied) S
o Vacant V
o Commercial (Describe on back) C
Description of Golf Cart (If applicable):
Serial #: Value: $
BILLING INFORMATION
o AGENCY BILL o DIRECT BILL
IF DIRECT BILL, BILL TO: o Applicant o Lienholder
Check Amount Enclosed $ ______________
IOWA MOBILE HOME APPLICATION
PRINT OR TYPE ALL INFORMATION!
