Conan Insurance - Mobile Home Form

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
1

MORTGAGEE:

ADDRESS:

LOAN NO.:

COVERAGE AND LIMIT INFORMATION

	Deductible $	Limit Of Liability
Mobile Home - Comprehensive
Mobile Home - Named Perils
Adjacent Structures - Comprehensive
Adjacent Structures - Named Perils
Personal Effects - Comprehensive
Personal Effects - Named Perils
Liability - Premises Liability
Additional Coverages - Vendor’s Single Interest
Additional Coverages - Flood Coverage
Additional Coverages - Trip Coverage

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
1
2

COVERAGE INFORMATION

Occupancy:

OwnerTenantVacantSeasonal

Protection Class:

Fire District:

Deductible Amount: $

Territory:

NADA Value: $

Distance to fire hydrant:

Distance to fire station:

Distance from water source:

Is mobile home located in flood zone?

YesNo

Is mobile home tied down?

YesNo

Is mobile home skirted?

YesNo

Is mobile home in park?

YesNo

Park size (acres):

Number of lots:

Are there any modifications to the home?

YesNo

Describe:

Is there a wood/coal burning facility?

YesNo

Provide questionnaire and photo.

Upload Photo

Is there a trampoline?

YesNo

Is there a swimming pool?

YesNo

Pool is:

Above groundBelow groundFenced

Applicant’s occupation:

Is there any business, including day care, conducted on premises?

YesNo

Explain:

Is there any acreage or outbuildings?

YesNo

Describe:

Does Applicant own any animals?

YesNo

What type and breed?

Any bite/aggressive behavior history?

YesNo

Previous insurance carrier:

Policy number:

Expiration date:

If no previous carrier, why (not applicable in Missouri or California)?

Has any company canceled or refused coverage to the Applicant (not applicable in Missouri or California)?

YesNo

Comments:

Any bankruptcy or foreclosure proceedings filed?

YesNo

Reason:

Discharged?

YesNo

Date of discharge:

Has the applicant ever been charged with arson or fraud?

YesNo

Any losses at this location or any other location owned/rented within the last three years?

YesNo

Please describe:

	Date	Description	Amount
1
2
3

PRIVACY POLICY: I have received and read a copy of the “National Casualty Company Privacy Statement and Procedures.” By submitting this application, I am applying for issuance of a policy of insurance and, at its expiration, for appropriate 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, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include 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 Agents Only)