III. ADDITIONAL PROPERTY INFORMATION
Please complete the following:
Age of roof __________yrs. Plumbing updated (yr) _________ Electrical updated (yr) __________ Heating updated (yr) _________
Roof type: q Flat q Wood shake q Shingle q Metal q Tile q Slate q Other ____________________
Plumbing type: q PVC q Copper q Lead q Galvanized q Other _____________________
What type of burglar alarm is on the premises? q Central station q Local q None
Number of years in business at the current location ________________________
IV. ELIGIBILITY CRITERIA
1. No past, pending or planned foreclosure and/or bankruptcy or judgment for unpaid taxes against the named
insured or any officer, partner, member or owner of the applicant individually within the past five years q True q False
2. Coverage has not been cancelled or non-renewed in the last three years (not applicable in Missouri) q True q False
If “False,” advise reason _____________________________________________________________________________
General Liability
1. No distribution, sale or filling of Liquefied Petroleum Gas (a.k.a. LPG, Propane) q True q False
(Tank exchanges that are not filled on premises are acceptable)
2. No assisted living or group home facilities q True q False
3. Applicant does not provide waste management, water treatment, electricity generation or other utilities
(other than water wells, septic tanks or sub metering of electricity) q True q False
4. No buying or selling of homes or operations as a dealer q True q False
5. Not an RV park or campground q True q False
6. All homes are required to be skirted q True q False
7. All lease agreements are for a minimum of six months q True q False
8. No exposure to lakes, golf courses, country clubs, day care, airports/air strips or resort activities q True q False
9. No direct exposure to the hook-up or tie-down of any mobile homes (except if subcontracted) q True q False
10. All subcontractors hired to hook up or tie-down mobile homes are required to carry a minimum of
$1,000,000 occurrence, name the applicant as additional insured, and provide a certificate of insurance
confirming all of the above q True q False
11. All swimming pools are fenced with self-latching gate, with depths clearly marked, pool rule clearly posted,
life safety equipment stored within pool area without any diving board or slide exposure q N/A q True q False
12. For any building built prior to 1978, 100% of the electric wiring is on functioning and
operating circuit breakers with a minimum of 100 AMP service q N/A q True q False
13. For any building built prior to 1978, there is no aluminum or knob and tube wiring q N/A q True q False
14. Functioning and operational smoke and/or heat detectors in all units and/or occupancies q True q False
(Mobile Homes Rented to Others) - if applicable
1. Applicant re-keys all locks prior to leasing to new tenants q True q False
2. All habitational units have functioning and operational carbon monoxide detection alarms if required
by the law or code of the municipality in which the building is located q True q False
Property
1 Functioning and operational fire extinguishers readily available q True q False
2. Functioning and operational smoke and/or heat detectors in all units an/or occupancies q True q False
3. Business does not operate on a seasonal basis q True q False
V. ADDITIONAL APPLICANT INFORMATION
Form of business: q Individual q Corporation q Partnership q LLC q Other ____________________________
What year did the business start? ________________________________
Applicant’s mailing address: ____________________________________________________ (if different than the location address above)
City: ______________________________________________________ State: ______________________ Zip: ________________________
E-mail address of primary contact: _____________________________________________ Phone: ____________________________________
Inspection contact name: _______________________________________ Telephone/E-mail address: ___________________________________
Audit contact name: ____________________________________________ Telephone/E-mail address: ___________________________________
Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any
affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such
statement was material to the risk when assumed and was untrue.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of
the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.”
Colorado Fraud Statement: 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.
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