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MOBILE HOME Special All Purpose FRONT & REAR (Risk Placement Services, Inc.)

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VI4190A09010
MOBILE HOME
Special
All
Purpose
Principal Residence (Owner)
Seasonal Residence (Owner)
Tenant Occupied
Commercial
FRONT & REAR PHOTOS OF DWELLING AND OTHER STRUCTURES REQUIRED
Requested Effective Date:
Policy Term:
3 Months
6 Months
12 Months
Name
BROKER NO
Mailing Address
BROKER NAME
City
County
State
Zip
ADDRESS
Social Security #(Insd)
(Spouse)
PHONE
FAX
EMAIL
Employer & Occupation:
(Insd)
(Spouse)
DOB (Ins):
(Spouse)
Married
Single/Separated
Mortgagee:
Prior Address
(If new purchase):
Address:
Street Address or Legal
Description
# Of Acres:
County:
City/St/Zip
Loan #
DESCRIPTION OF MOBILE HOME
Year
Make/Mode
l
L
e
ngth
Width
Date
Purchased
Purchase
Pric
e
DESCRIPTION OF OTHER STRUCTURES
VALUE
1.
2.
3.
UNDERWRITING REQUIREMENTS
PREMIUM
LIMIT
PREMIUM
IF ANSWERED
“
Y
ES”
SUBMIT FOR PRIOR APPROVAL
YES NO
Mobile Home
$
1. Has applicant had similar insurance canceled or non-renewed during past 30 months?
Adjacent Structures
$
2. Has the applicant had a fire, water or liability loss (whether paid or not by ins)?
Mobile Home & Adjacent Structures
Comp
Named Perils
$
3. Have there been 2 or more claims in the past three years?
Personal Effects
$
4. Are there any pending open claims?
Comprehensive Personal Liability/OLT
5. Is there a wood burning stove, space heater or fireplace?
1 Previous Loss
+10%
6. Has the applicant filed bankruptcy in past 36 months?
2 Previous Losses
+25%
7. Is there a swimming pool or trampoline?
Insured Age 50 Years Old and Older (LOB 37)
-10%
8. Is there a home day care exposure?
Insured Age 60 Years Old and Older (LOB 37)
-14%
9. Does the applicants own, keep or shelter any Akita, Anatolian Shepherd, Chow,
Doberman, Pit Bull, Presa Canario, Rottweiler, Wolf or Wolf hybrid, any mix of these
breeds with any other breed, whether listed or not?
Insured Age 50 Years Old and Older (LOB 48)
- 5%
Claim Free Transfer (furnish prior Dec) (LOB 37)
-10%
10. Are there any vicious or exotic animals on premises?
No Lienholder
- 5%
11. Has the mobile home been uninsured for more than 30 days prior to effective date?
12. Is there a commercial or farm exposure? Multiple horses, livestock or farm animals?
Wood Stove/Fireplace/Space Heater
$
IF ANSWERED “YES” PLEASE EXPLAIN:
OPTION
AL
COVERAGES
No
Flat
Ca
nc
e
lla
ti
on
Deductible $1,000
$
Replacement Cost Home
$
Replacement Cost Contents
$
Golf Cart
$
13. Is there any existing damage (inside or out)?
Scheduled Personal Property
$
14. Other structures on premises (submit photo, dimensions & value of each structure)?
Other:
$
15. Is the mobile without steps & handrails on any exit?
Other:
$
IF ANSWERED
“N
O
”
DO NO T SUBMIT
:
GROSS PREMI UM
$
16. Is the mobile home tied down and skirted?
Policy Fee
$ 50.00
IF ANSWERED
“
Y
ES”
DO NOT SUBMIT—COVERAGE CANNOT BE BOUND
6% Tax (On premium & Fee)
$
17. Has a representative of your agency NOT personally inspected risk in the last 60 days?
TO TAL AMOUNT DUE
$
18. Is the mobile home isolated or not easily accessible by public roads?
MINIMUM EARNED - $50.00 (Plus Fee & Tax)
19. Is the risk in foreclosure or have past due mortgage payments?
20. Is the mobile home vacant?
FIRE PROTECTION - Subscription? Yes No Does Not
Apply
21. Is the mobile home under construction or renovation?
Territory A
B
F.D. Name:
If subscription, PD Y
N
22. Has the applicant been convicted of arson or insurance fraud?
Protection Class:
MH Park:
# Lots:
Inside City Limits: Y
N
Distance to Hydrant:
Distance to Station:
ADDITIONAL REQUIREMENTS
:
PRIOR INSURANCE
1. Description of golf cart & serial # if insured
Previous Carrier:
2. Description of scheduled personal property if insured
Policy #:
Exp. Date:
3. If the property is located in a rural fire protection district or in an area protected
If no prior ins., state reason and date of last
policy:
by a rural fire department requiring a subscription, must provide proof of payment
LOSS HISTORY (past 3 years)
or will be rated as unprotected.
(Use Separate Sheet if necessary, if none – so state)
Date
Cause
Amount
Date
Cause
Amount
APPLICANTS SIGNATURE
COMMENTS:
I understand that no insurance is bound hereunder and agree that
no
insurance shall be effective
until this
application
is
approved
by
RPS Inc. and that coverage may be written with a non-admitted market. I further agree that the
foregoing
statements
and
answers
are true and
correct and request RPS
Inc to
issue the insurance
policy and any renewals
thereof
in
reliance thereon. As part of the company’s normal underwriting procedure an investigation may be made which will
provide applicable information concerning character, general reputation, personal characteristics, mode of living, credit and
condition of the property to be insured. Upon written request, additio nal information as to the nature and scope of the report, if one is
made, will be provided.
Date:
Time:
AM
PM
Agent’s Signature:
Applicant’s Signatu
r
e
:
(Circle one)
click to sign
signature
click to edit
click to sign
signature
click to edit
VI4190A09010
PLEASE REFER TO MANUAL FOR RATES
POLICY TERM
12 Months – See Rates + Fee/Tax
6 Months – Annual X 55% + Fee/Tax
3 Months – Annual X 30% + Fee/Tax
Fee is $25.00 per policy Tax is 6%
of premium plus fee Minimum
Premium $50 + fee & tax
Special Mobile
Home
Territory
A:
Owner occupied as primary or seasonal residence of named insured.
No age requirement
Adair
Comprehensive perils on mobile home and contents
Insurance basis on mobile home is actual cash value
Canadian
Cherokee
All Purpose Mobile
Home
Cleveland
Craig
Rental and commercial mobile homes
Commercial restricted to offices, construction offices, mobile
Creek
Delaware
classrooms, display units, libraries, etc.
Insuring basis on mobile home is actual cash value
Hughes
Kay
Contents coverage up to $10,000
Lincoln
Logan
McIntosh
The following exclusion endorsements will be added to the policy
if
Liability
is
purchased and bodily injury, property damage or any other
loss
or expense arising out of an occurrence involving these listed exclusions
will not be covered:
Mayes
Wagoner
Muskogee
Washington
Noble
War and Terrorism Exclusion
Territory
B:
Absolute Animal Liability Exclusion
Hazardous Substance Liability Exclusion
Remainder of State
Trampoline Exclusion
Mold Exclusion
Assault and Battery Exclusion
Sexual Misconduct or Sexual Molestation Exclusion
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Completed 30 July 2020

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