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MANUFACTURED HOME APPLICATION (Risk Placement Services, Inc.)

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A4436A0710
1
of 2
ARIC MH MN
MANUFACTURED HOME APPLICATION
Preferred (LOB 46)
Special (LOB 37)
Special By-Line (LOB 77)
All Purpose (LOB 48)
APP
LICANT INFORMATION PRODUCER
Applicant
Agency Name:
Agen
Address
REQUEST POLICY TERM
City
State
Zip
From: To: Time: AM PM
County
Phone No.
Policy Term: 12 Months
Occupation
Employer
(If Self
-
Employed, list “SELF”)
BINDING AUTHORITY: For coverage to begin as requested, the
application must be mailed within 72 hours of the effective date of
coverage. Otherwise, coverage is bound at 12:01 a.m. the day it is received
by the General Agent. No coverage may be increased within 72 hours of
the announcement of an impending disaster, i.e. hurricane, tropical storm,
volcanic eruption, earthquake, flood, mudslide, brushfire, etc.
Social Security #
DOB
Co
-
Applicant Name
Co
-
Applicant Social Security #
DOB
Co
-
Applicant Occupation
Co
-
Applicant’s Employer
LOCATION
Add’l Insured
Address, if different than mailing address (include city, state, zip and county)
Park Name: ____________________________________________________________
Address: _______________________________________________________________
______________________________
________________________________________
Address
City
State
Zip
BILLING / ACCOUNTING INFORMATION
BILL TO: Insured Lienholder
*PAYMENT PLANS: If the insured desires to pay their premium on an installment basis, the Company will allow a 2-payment, 4-payment, or 8-payment option to be selected.
Check #______ Check Amt $___________
1
-
Pay, 100% payment, plus any applicable taxes and fees
2-Pay, 50% down, plus any applicable taxes and fees
4
-
Pay, 25% down, plus any applicable taxes and fees
8-Pay, 20% down, plus any applicable taxes and fees
* Each installment (not applicable to the down payment)
includes a $6 fully earned service charge
LIENHOL
DER
Name
Loan #
Name
Loan #
Address
Address
City
State
Zip
City
State
Zip
GENERAL INFORMATION
Territory
Model Year
Protection Class
Feet to Fire Hydrant
Miles to Fire Dept.
Inside City Limits?
Supplemental Heating Device
None
Wood/coal/pellet burning Stove
Yes No Woodburning Fireplace Gas Fireplace
Other: ____________________________
Manufacturer/Model
Serial Num
ber
Length
Width
Skirted?
Tied Down?
Purchase Date
Purchase Price
Current Value
Yes
No
Yes
No
$
$
Describe Additions/Attached Structures:
Age
Size
$
Describe Unattached Other Str
uctures:
Age
Size
$
MUST COMPLETE THE FOLLOWING
(Place an “X” in the appropriate boxes.)
Usage:
Primary Seasonal/Secondary Commercial
Rental (If Rental, is home currently occupied by tenant? Yes No
Age Of Insured: 49 & Under 50 - 59 60 & Over
Age Of
Manufactured Home:
0-2 3-4 5-6 7-8 9-10 11-20 21 & Over
Park Status: Out of Park # of acres: _______ In a Park # of spaces: ________
Claim Free Transfer: Yes* No
*(Must have had continuous prior insurance for the past 36 months with no claims. A current renewal
offer, declarations page, or other evidence of insurance dated within the past 30 days is required.)
How long has applicant lived in the Manufactured Home? ______________________
Prior Insurance: Yes No New Purchase
Prior Company: ____________________________________________________________
Animals On Premises: Yes No
Type of Animal: ______________________ Breed of Dog: ___________________________
POLICY INFORMATION
COVERAGES
LIMITS
PREMIUM
Manufactured Home and Additions
$
Other Structures
Personal Property
Personal or Premises Liability
Medical Payments to Others
BASE PREMIUM:
$
Claim Free Transfer Credit: BASE PREMIUM __________________ X 5%
Supplemental Heating Surcharge
Optional Deductible (List Deductible) $________________________
Replacement Cost – Manufactured Home (15 Years & Newer)
Replacement Cost – Personal Property
Other Optional Coverages:
SUBTOTAL:
$
Fire Safety Surcharge: SUBTOTAL ____________________________ X 0.65%
City Fire Surcharge (If applicable): SUBTOTAL ________________X 35% X 2%
Minimum Written Premium is $50
TOTAL PREMIUM:
$
ATTACH PHOTOS IF NECESSARY
A4436A0710
2
of 2
ARIC MH MN
LOSS HISTORY
HAVE YOU HAD ANY PRIOR LOSSES? Yes No If Yes, indicate below.
Description of Loss Date Amount Paid
Description of Loss Date Amount Paid
Description of Loss Date Amount Paid
If the applicant has had 2 or more property losses (paid or unpaid) in the past 36 months or any single fire, theft, liability or water loss in the past 36 months, the risk must be
submitted to the General Agent for acceptability.
UNACCEPTABLE RISKS – DO NOT SUBMIT, DO NOT BIND
Any “Yes” response makes the risk unacceptable and it cannot be written!
Yes No
1. Has the applicant been convicted of arson or insurance fraud? .................................................................................................................................................................................................
2. Is the home without permanently installed water, electricity and sewage utility services? .......................................................................................................................................................
3. Has the home been salvaged or have existing structural damage? ...........................................................................................................................................................................................
4. Is the home vacant or under construction/major renova
tion? .....................................................................................................................................................................................................
5. Is the home in foreclosure? ...........................................................................................................................................................................................................................................................
6. Does the home have a liquid fuel-powered space heater or existence of any heat-reclaiming device? .................................................................................................................................
7. Is the primary source of heat a wood/coal/pellet burning device? . ...........................................................................................................................................................................................
8. Does the home have other structures or garages with a wood/coal/pellet burning device? .....................................................................................................................................................
9. Does the home have polybutelene pipes? ...................................................................................................................................................................................................................................
10. Is the home or other structures used to store flammables or explosive materials?...................................................................................................................................................................
11. Does the home have a brush clearance of less than 350 feet? .................................................................................................................................................................................................
12. Does the home have more than 2 lien holders? Two lien holders are acceptable if one is a financial institution. ..................................................................................................................
13. Does the home have childcare, homecare, lodging, auto repair or chemical processing conducted on the premises? All other business pursuits must be submitted
for approval. ..................................................................................................................................................................................................................................................................................
RISK TO BE WRITTEN WITHOUT LIABILITY COVERAGE
Any “Yes” Response Must Be Explained Below.
Yes No
1. Does the applicant own, keep, or shelter any animal with a previous bite history or any non-domestic animal? ...................................................................................................................
2. Are owner occupied risks in the name of a corporation? ............................................................................................................................................................................................................
SUBMIT RISKS TO GENERAL AGENT
Any “Yes” Response Must Be Explained Below.
Yes No
1. Has the applicant had 2 or more property losses (paid or unpaid) in the past 36 months or any single fire, theft, liability or flood loss in the past 36 months? If yes, give
date of loss, describe the loss and the amount paid to repair the damage. ...............................................................................................................................................................................
2. Has the applicant had a manufactured home/dwelling policy cancelled or non-renewed for underwriting reasons (except age of unit) during the past 36 months? ...............................
3. Has the applicant filed for bankruptcy in the past 36 months? .................................................................................................................................................................................................
4. Has the applicant been 30 days past due on mortgage payments in the last 12 months?.......................................................................................................................................................
5. Is applicant unemployed? (Retirees with guaranteed income and disabled persons with a consistent income are considered employed.). ......................................................................
6. Has the home been uninsured for more than 30 days immediately prior to the requested effective date. (Does not apply to a new purchase) .................................................................
7. Does the home have more than 2 unrelated owners? ................................................................................................................................................................................................................
8. Is the home built on stilts, posts or piers? Ph
otos must be included ......................................................................................................................................................................................
9. Is the home or any other structures (other than porches, decks, awnings, skirting or carports) that are not factory/contractor built or two separate homes that are joined together?
Photos must be included. ...........................................................................................................................................................................................................................................................
10. Is the home equipped with a supplemental heating device that was not installed by the manufacturer or a licensed contractor? Photos and the Woodstove Inspection
Report must be included. ...........................................................................................................................................................................................................................................................
11. Does the home have 3 or more steps on any exit without a handrail? Photos must be included. .......................................................................................................................................
12. Is the home without permanently installed steps at all entrances? Photos must be included. ............................................................................................................................................
13. Is there a swimming pool or spa that does not have a four-foot fence with a self-latching gate, motorized pool cover, or other comparable safety device that is
securely fastened to the perimeter of the pool/spa thus rendering it inaccessible? ..................................................................................................................................................................
14. Is the home within 1,500 feet of water (river, creek or ocean) or is it located on an island or in a Special Flood Hazard Area? ...........................................................................................
15. Does the home have multiple horses, livestock or farm animals on the premises? ..................................................................................................................................................................
16. Is there a dock, pier or boathouse? Photos must be included. ...............................................................................................................................................................................................
17. Does the premises have 5 or more acres? ..................................................................................................................................................................................................................................
18. Are farming activities conducted on the premises? .....................................................................................................................................................................................................................
19. Are business pursuits conducted on the premises? ....................................................................................................................................................................................................................
20. Are there unattached structures that exceed 31% of the insured value of the manufactured home? .....................................................................................................................................
21. Do personal effects exceed 71% of the insured value of the manufactured home? Personal Effects Inventory must be included. ...............................................................................
Explain “Yes” answers
SPECIFIC BREED ANIMAL EXCLUSION (Only applicable to specific breeds/animals): I understand the Specific Breed Animal Exclusion will be attached to my policy and that bodily injury, property damage or
any other loss or expense arising out of any occurrence involving any of the following types of animals and/or breeds of dogs will not be covered: Any animal with a previous bite history, snakes, monkeys or
ostriches; Breeds of dogs include Akita, Anatolian Shepherd, Chow, Doberman, Pit Bull, Presa Canario, Rottweiler, Wolf, Wolf Hybrid, or any mix of these breeds with any other breed whether listed here or not.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claims containing any materially false information
or conceals, for the purposes of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may subject such person to criminal and substantial civil
penalties.
NOTICE CONCERNING POLICYHOLDER RIGHTS IN AN INSOLVENCY UNDER THE MINNESOTA INSURANCE GUARANTY ASSOCIATION LAW: The financial strength of your insurer is one of the most
important things for you to consider when determining from whom to purchase a property or liability insurance policy. It is your best assurance that you will receive the protection for which you purchased the policy. If
your insurer becomes insolvent, you may have protection from the Minnesota Insurance Guaranty Association as described below but to the extent that your policy is not protected by the Minnesota Insurance
Guaranty Association or if it exceeds the guaranty association's limits, you will only have the assets, if any, of the insolvent insurer to satisfy your claim.
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 agents 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.
NOTICE OF POSSIBLE CANCELLATION: THE INSURER MAY ELECT TO CANCEL COVERAGE AT ANY TIME DURING THE FIRST 59 DAYS FOLLOWING ISSUANCE OF THE COVERAGE FOR ANY
REASON WHICH IS NOT SPECIFICALLY PROHIBITED BY STATUTE.
X
X
MUST BE SIGNED (Signature of Applicant) Date MUST BE SIGNED (Signature of Producer) Date
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Completed 30 July 2020

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