MH-APP (3-07) Page 1 of 3
Mobile Home Application
Applicant’s Name Agent Name
Mailing Address Address
Location of M.H.
Agent Code
PROPOSED EFFECTIVE DATE: From To
12:01 A.M., Standard Time at the mailing address of the Applicant
MOBILE HOME INFORMATION PHOTO REQUIRED
Year Length Width Make & Model Serial Number
Actual Value
When Insured
Purchased
Mo. Yr.
Purchase
Price
MORTGAGEE:
ADDRESS: LOAN NO.:
COVERAGE AND LIMIT INFORMATION
Item Coverage Deductible Limit Of Liability
Comprehensive $
Mobile Home
Named Perils $
Comprehensive $
Adjacent
Structures
Named Perils $
Comprehensive $
Personal
Effects
Named Perils $
Liability Premises Liability $
Vendor’s Single Interest $
Flood Coverage $
Additional
Coverages
Trip Coverage $ From To
Adjacent Structures—List adjacent structures and equipment (cabanas, awnings, sheds, carports, air conditioners, etc.)
Notice to Agent: Must schedule on form UT-258g if structure not listed in policy.
Description Value Description Value
COVERAGE INFORMATION
1. Occupancy: Owner Tenant Vacant Seasonal
2. Protection Class: Fire District:
MH-APP (3-07) Page 2 of 3
3. Deductible Amount: $
4. Territory:
5. NADA Value: $
6. Distance to fire hydrant:
7. Distance to fire station:
8. Distance from water source:
9. Is mobile home located in flood zone? ....................................................................................................... Yes No
10. Is mobile home tied down?..........................................................................................................................
Yes No
11. Is mobile home skirted?............................................................................................................................... Yes No
12. Is mobile home in park? .............................................................................................................................. Yes No
13. Park size (acres): Number of lots:
14. Are there any modifications to the home? .................................................................................................. Yes No
If yes, describe:
15. Is there a wood/coal burning facility? .......................................................................................................... Yes No
If yes, provide questionnaire and photo.
16. Is there a trampoline?.................................................................................................................................. Yes No
17. Is there a swimming pool?........................................................................................................................... Yes No
If yes, pool is: Above ground Below ground Fenced
18. Applicant’s occupation:
19. Is there any business, including day care, conducted on premises?.......................................................... Yes No
If yes, explain:
20. Is there any acreage or outbuildings? ......................................................................................................... Yes No
If yes, describe:
21. Does Applicant own any animals?............................................................................................................... Yes No
If yes, what type and breed?
Any bite/aggressive behavior history? .............................................................................................................................. Yes No
22. Previous insurance carrier:
Policy number: Expiration date:
If no previous carrier, why (not applicable in Missouri or California)?
23. Has any company canceled or refused coverage to the Applicant (not applicable in Missouri or
California)? ..................................................................................................................................................
Yes No
Comments:
MH-APP (3-07) Page 3 of 3
24. Any bankruptcy or foreclosure proceedings filed? ...................................................................................... Yes No
Reason:
Discharged?................................................................................................................................................. Yes No
Date of discharge:
25. Has the applicant ever been charged with arson or fraud?......................................................................... Yes No
26. Any losses at this location or any other location owned/rented within the last three years? ..................... Yes No
If yes, please describe:
Date Description Amount
PRIVACY POLICY: I have received and read a copy of the “National Casualty Company Privacy Statement and Proce-
dures.” By submitting this application, I am applying for issuance of a policy of insurance and, at its expiration, for appro-
priate renewal policies issued by National Casualty Company and/or other members of the Scottsdale group of insurance
companies. I understand and agree that any information about me that is contained in, or that is obtained in connection
with this application or any policy issued to me may be used by any company within the Scottsdale group to issue, review,
and renew the insurance for which I am applying.
FAIR CREDIT REPORTING ACT NOTICE: This notice is given to comply with Federal Fair Credit Reporting Act (Public
law 91-508) and any similar state law which is applicable as part of our underwriting procedure. A routine inquiry may be
made which will provide information concerning character, general reputation, personal characteristics and mode of living.
Upon written request, additional information as to nature and scope of the report will be provided.
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 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.
FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON): It is a crime to knowingly provide false, in-
complete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties in-
clude imprisonment, fines, and denial of insurance benefits.
FRAUD WARNING APPLICABLE IN THE STATE OF 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 also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
APPLICATION WILL NOT BE ACCEPTED WITHOUT APPLICANT’S AND PRODUCER’S SIGNATURES.
Applicant’s Signature:
__________________________________________________________ Date:
Producer’s Signature: __________________________________________________________ Date:
Agent Name: Agent License No.:
(Applicable to Florida Agents Only)
Iowa Licensed Agent:
(Applicable in Iowa Only)