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Manufactured Home Insurance Questionnaire
Call Us Today At
(281) 550-5864
Manufactured Home Insurance Questionnaire
General Information Section
First Name (Primary)
Last Name
Date of Birth
Occupation
First Name (Secondary/Spouse)
Last Name
Date of Birth
Occupation
Home Phone
Mobile Phone
Work Phone
Email Address
Physical Address
Please indicate your preferred method of communication:
Voice/Phone
Email
Fax
Text
Manufactured Home Section
MANUFACTURED HOME DEFINED:
Please note that the insurance carrier considers a Manufactured Home that is used as a single family residence to be sitting on a permanent slab foundation bolted down with posts assembled onsite in sections piece by piece. This is for clarification and to avoid confusing Manufactured Homes with Double Wide Mobile Homes which are built on a trailer frame and then just attached together.
Manufactured Home Use
Primary
Primary Farm/Ranch (Applies to Primary use risks when Farm/Ranch operations exceed our Hobby Farm Definition)
Secondary
Tenant (Renter's personal property & liability) NOTE: Insurance on the home can be placed through our Rental Manufactured Home Program.
DOES THE FIRST NAMED INSURED RESIDE IN THE HOME?
Yes
No
IS THE SECOND NAMED INSURED A RESIDENT FAMILY MEMBER OF THE FIRST NAMED INSURED?
Yes
No
If NO, does the second insured have an insurable interest and reside in the home?
Yes
No
Insured Type - All Others N/A Tenant
ENTITY THAT APPEARS ON THE TITLE OR DEED:
First Individual with Control
LAST NAME
FIRST NAME
MIDDLE INITIAL
DATE OF BIRTH
Second Individual with Control
LAST NAME
FIRST NAME
MIDDLE INITIAL
Manufactured Home Location Address
HOME LOCATED INSIDE INCORPORATED CITY LIMITS?
Yes
No
IS HOME IN PARK/COMMUNITY?
Yes
No
PARK/COMMUNITY NAME LOT NO.
Manufactured Home Location Address (Street, City, Zip )
Manufactured Home Information
DOES THE MANUFACTURED HOME OR OTHER STRUCTURE HAVE A WOODSTOVE OR FIREPLACE?
No
Factory Installed
Commercially Installed
Self-Intalled
Manufactured Home Information
Model Year
Width
Length
Make/Model
Serial No.
MANUFACTURED HOME TIED DOWN?
Yes
No
DATE OF PURCHASE
PURCHASE PRICE
COVERAGE AMOUNT: (Include attached additions but exclude land value.)
IS THIS A MODULAR HOME?
Yes
No
Underwriting Questions
Has the applicant had any losses in the past 5 years?
Yes
No
If YES, provide loss information
Any theft or liability loss greater than $2,500? Any water loss with unrepaired damage?
Yes
No
Any water related losses greater than $5,000?
Yes
No
Two or more water losses from same cause?
Yes
No
Fire loss of any kind?
Yes
No
Three or more losses of any kind?
Yes
No
Has the applicant’s policy been canceled/non-renewed (including non-pay) in the past 5 years?
Yes
No
Was the reason non-pay or because the company/agent had withdrawn from product/state?
Yes
No
Has the applicant had 3 or more policies cancel for non-pay in the past 5 years regardless of policy type?
Yes
No
Has the applicant had a lapse in insurance coverage of more than 12 months?
Yes
No
Please list the name of the policy that lapsed & give the reason for the lapse.
Is the manufactured home raised more than 4 feet on any side? N/A tenant use?
Yes
No
Was it approved by a state, county or local official?
Yes
No
Any farm or ranch activity conducted on the premises, including owning farm animals?
Yes
No
If YES, provide loss information
Does activity meet the Hobby Farm definition?
Yes
No
If yes, do you want the Hobby Farm Endorsement? (Only available when liability is added)
Yes
No
Does the applicant own or keep on the premises any non-domestic animal, including any exotic or wild animal?
Yes
No
Describe animal.
Does the applicant own or keep on the premises an animal that has caused harm or previously bitten?
Yes
No
Is the manufactured home or adjacent structure utilized as a commercial risk or is business conducted on premises, including day care? If YES, and tenant use, risk is unacceptable.
Yes
No
Is the business incidental?
Yes
No
Is the manufactured home currently vacant, excluding a new purchase that will be occupied within 60 days?
Yes
No
NOTE: If the manufactured home risk is unacceptable due to vacancy
Yes
No
Is the manufactured home fully installed and connected to utilities?
Yes
No
If NO, will it be fully installed and connected within 60 days? NOTE: Requires Trip Coverage. N/A tenant use
Yes
No
Does the manufactured home have additions with heat or plumbing?
Yes
No
Was the addition approved by a state, county or local official?
Yes
No
Is any other structure a manufactured home, site built home, farm building or larger than 1200 sq. ft.?
Yes
No
If YES and structure is insured with another company, list here and notate policy.
If YES and structure is not insured with another company, submit with photos and describe how structure is used.
Is there a pool over 2.5 ft. on the premises?
Yes
No
Does it meet our fence and gate requirements?
Yes
No
Signature
*
Name
*
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