Document Sample
					                                                                                                     All Risks, Ltd.
      Markel American                                       MOBILE HOME                      9030 Stony Point Pkwy, Suite 230
                                                                                                  Richmond, VA 23235
      Insurance Company                                     APPLICATION                           Phone: (800) 366-7475
                                                                                                   Fax: (804) 330-9485
                       NAMED INSURED                                                 REQUESTED POLICY TERM
 Name                                      DOB     /     /            From             To          Policy Term: 12 Months
 Address                                                              Time            AM/PM
 City                          State         Zip                      See Binding Rule – “Submit” risks cannot be bound.
 County                        Phone No. ( )
                                                                      Agency Code
 Social Security #
                                                                      Agency Name
 Spouse Social Security #
 Add’l Insured
                                                                      City                        State
                                                                      Zip                      Phone No.(      )
 City                          State         Zip
 Park Name
 Address, if different than above (include county & zip)
                                                                      City                           State         Zip
                                                                      Loan #
 Distance of unit to fire hydrant        feet Protection              Name
 Distance of unit to fire station      miles Class                    Address
 Is Mobile Home located inside city limits?    Yes       No           City                           State         Zip

  Year   Manufacturer/Model      Length Width Serial Number Purchase Year   Purchase Price Current Value
                                                                          $                $
  Describe Additions/Attached Structures:                                   Age      Size
  Describe Unattached Structures:
            MUST COMPLETE THE FOLLOWING                                               POLICY INFORMATION
INSURED AGE:   ❏ < 45 yrs                   ❏ 45+ yrs               RATES:    ❏ Package      ❏ Standard      ❏ Tenant
SUPPORTING BUSINESS: ❏ Yes (submit copy of Declarations Page)   ❏             ❏ Rental
                                                                       COVERAGES                 LIMITS            PREMIUM
LIENHOLDER:    ❏ None     ❏ One             ❏ Two
                                                                    Mobile Home                                 (Base Premium) ❏
PARK STATUS:     ❏ In a Park _____ # of spaces ❏ Out of Park
USAGE: ❏ Permanent         ❏ Seasonal                               and Additions         $                     $
        ❏ Rental           ❏ Tenant                                 Unattached                                  ❏ If Package rate
TIE DOWNS:       ❏ Tied Down         ❏ Not Tied Down                Structures            $                     $
SUPPLEMENTAL HEATING:                                               Personal Effects                            ❏ If Package rate
❏ None    ❏ Woodburning Stove ❏ Fireplace ❏ Other                                         $                     $
PRIOR INSURANCE: ❏ No          ❏ Yes              ❏ New Purchase    Personal Liability                          ❏ If Package rate
Prior Company & Policy #                                            Med Pay    ❏ $500
                 BILLING INFORMATION                                           ❏ $1,000 $                       $

❏ One Pay – 100% Policy Premium      ❏ Two Pay – 50% down + $5
                                                                    DEDUCTIBLE                Credit/Debit
❏ Four Pay – 25% down + $5           ❏ Eight Pay – 16% down + $5    $                        (if applicable)    $
❏ Mortgagee Bill                     ❏ Credit Card                  Supplemental Heating Surcharge- Add $30     $
                                                                                Optional Coverages
                       Credit Card Info                                                                            $
  ❏ MasterCard              ❏ Visa            ❏ Discover
  Card #:__________________________________________                                                                $
  Exp. Date:________ Name on Card: ______________________                                     POLICY
 Down Payment                           $ _______________
 Service Charge                         $ _______________
 Check Amount Enclosed                  $ _______________

                                     QUALIFICATION CRITERIA – Refer to rules in rate guide
                                   ANY “YES” RESPONSE MAKES THE RISK UNACCEPTABLE                                                 Yes    No
1.    Is the home without utility service or not easily accessible from public roadways?                                          ❏       ❏
2.    Is the home located in an area subject to mudslides, brush fires or high crime?                                             ❏       ❏
3.    Are there more than 2 lienholders on the home?                                                                              ❏       ❏
4.    Is the home vacant or unoccupied for more than 6 months? (Seasonal or secondary risks are acceptable)                       ❏       ❏
5.    Is the home joined together or homemade?                                                                                    ❏       ❏
6.    Is the home used as lodging and rented on a daily or weekly basis?(If “Yes”, ineligible for Liability coverage)             ❏       ❏
7.    Does the general public enter the home frequently? (If “Yes”, ineligible for Liability coverage)                            ❏       ❏
8.    Is there a swimming pool, trampoline or other similar hazard located on the premises? (If “Yes”, ineligible for Liability   ❏       ❏
      coverage.) If the swimming pool is fenced with a locking gate and without a slide or diving board, risk may be
      submitted for Liability limits. Describe any play, athletic or exercise equipment:

9.    Are any entrances to the mobile home missing steps or have unstable steps or missing handrails?                             ❏       ❏
      (If “Yes”, ineligible for Liability coverage)
10.   Has any applicant had a foreclosure or repossession in the past 4 years or is behind in mortgage payments?                  ❏       ❏
11.   Are any vicious and/or wild (non-domestic) animals on premises? Any domestic animal with a past incident                    ❏       ❏
      resulting in injury is considered vicious. Risks with a Pit Bull Terrier, Doberman, Rottweiler, Akita, Chow or any wild
      (non-domestic) animal are ineligible for Liability coverage for these animals. Describe any animal(s) and pet(s) owned
      by the insured:
12.   Has any applicant been convicted of arson or fraud?                                                                         ❏       ❏
13.   Are there any activities being conducted on the premises such as wood-working, cabinet making, upholstery, auto             ❏       ❏
      repair or risks attached to taverns or restaurants, etc.?
14.   Does the unit have wood, coal or pellet burning stoves, heaters or fireplaces that are the primary source of heat or        ❏       ❏
      or any kerosene heaters, non-permanent space heaters or other potential hazardous supplemental heating devices?
15.   Has any applicant filed Chapter 7 bankruptcy?                                                                               ❏       ❏
                                      SUBMIT RISKS – Refer to rules in rate guide
                       ANY “YES” RESPONSE MUST BE EXPLAINED AND SUBMITTED UNBOUND                                                 Yes    No
1.    Is any applicant aware of any attached or unattached structures (other than porches, decks, awnings, skirting               ❏       ❏
      and carports) that are non-factory or non-contractor built? (If “Yes”, give dimensions and value of all additions on
      front of application)
2.    Is the value of the unattached structures greater than 50% of the value of the home or is the square footage                ❏       ❏
      greater than 100% of the mobile home?
3.    Does the value of the personal property exceed $20,000 and is 100% of the value of the home?                                ❏       ❏
      (Submit with Personal Property Inventory)
4.    Is the home in the course of construction or have any existing damage?                                                      ❏       ❏
5.    Has the home been owned by any applicant without prior insurance?                                                           ❏       ❏
6.    Is applicant unemployed? If unemployed, explain means of support:                                                           ❏       ❏
7.    Has any applicant had a fire, liability, theft loss or more than 2 losses of any type during the past 5 years?              ❏       ❏
      Describe dwelling losses of any type in the past 5 years.
      Date                 Type                                                                            Amount
      Date                 Type                                                                            Amount
8.    Has any applicant been cancelled, declined or non-renewed in the past 5 years?                                              ❏       ❏
9.    Are any business, childcare or farming activities conducted on the premises?                                                ❏       ❏
      If “Yes”, describe:
10.   Does the unit have wood, coal or pellet burning stoves, heaters or fireplaces used for supplemental heating that
      are not factory or commercially installed? (Submit a completed and signed certificate by the insured.)                      ❏       ❏
11.   Are there any horses or livestock on the premises?                                                                          ❏       ❏
12.   Is the mobile home located on a parcel of land greater than 5 acres?                                                        ❏       ❏
13.   Has any applicant filed for Chapter 13 bankruptcy?                                                                          ❏       ❏
14.   Is the home a corporate risk, a risk with multiple individuals as Named Insureds, or property sold on land contract?        ❏       ❏
      (If applicable, apply the Unrelated Named Insured surcharge.)
15.   Is the home a commercial risk?                                                                                              ❏       ❏
NOTICE: The normal procedure used by the company to evaluate applications may include obtaining an investigative consumer and credit
report involving information on such things as character, general reputation, personal characteristics and mode of living. Information on the
nature and scope of such a report, if one is made, will be given to you upon request.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.
I hereby apply for insurance and declare that all of the foregoing statements are true. I agree that the policy shall be null and void if such
information is false, misleading or would affect acceptance by the company.
Applicant’s Signature X                                                                                           Date
Agent’s Signature    X                                                                                            Date

                                                           THIS IS NOT A POLICY



Please Note: This policy does NOT cover losses from flood.

Generally, the mobile homeowner's insurance policy does not provide coverage for flooding, surface water that
enters the home or rising water. However, coverage for these types of losses may be available through the Federal
Government's National Flood Insurance Program ("NFIP") or through other sources, such as Markel American
Insurance Company.

You can obtain information about the National Flood Insurance Program by contacting your insurance company or
your insurance agent or by going on the internet to www.FLOODSMART.GOV or by calling 1-800-427-4661. Here
are some important facts you should know.

    -   Flood insurance policies are available for any home located in a community that is a participant in the

    -   Some lenders, as a condition of your mortgage, will require that you purchased flood insurance. You
        should confirm with your mortgage lender or the NFIP, before settlement, if you are required to purchase
        flood insurance. Even if you are not required to purchase flood insurance, you should consider purchasing
        it as additional protection for your home.

    -   You do not have to be located in a special flood hazard area or be close to a body of water to experience
        flooding. The risk of flood is present for most homes as floods can be caused by storms, melting snow,
        heavy rains, dam failures or other causes.

    -   You must complete a separate application in order to purchase flood insurance; it is not part of your
        homeowner's insurance application.

    -   Flood insurance policies have two types of coverage: structural coverage for your home and the items that
        are permanently attached and contents coverage for your personal property within the home. Structure and
        contents coverages are purchased separately and carry separate deductibles.

    -   Generally, there is a thirty (30) day waiting period for a new flood insurance policy to become effective;
        although there are some exceptions to this general rule.

    -   As flood insurance through the NFIP is created by federal law, flood claims are adjusted and paid in a
        different manner than your homeowner's insurance claims.

MA929-0107                                                                                                Page 1 of 1

                           NOTICE TO INSURED REGARDING
                          ADDITIONAL OPTIONAL COVERAGES

Your mobile homeowner's insurance policy does not cover all risks. You may need to obtain additional insurance to
cover loss or damage to your dwelling, personal property, and your liability or to cover the risks related to business
or personal activities on your property.

In addition to the coverages that are part of the mobile homeowner's insurance policy, we offer the following
additional coverages that you may choose to purchase:

    -    Coverage for Water Damage - for losses that result from water backing up through sewers or drains.

    -    Liability Coverage for Family Day Care providers - registered family day care providers can purchase
         liability coverage in the amount of at least $300,000 to protect you against claims of bodily injury, property
         damage, or personal injury arising out of your activities as a day care provider.

    -    Lender's Interest Protection - available on mobile homes with a lienholder. Your lienholder may require
         this coverage be added to your policy to protect their interest in the dwelling.

    -    Natural Disaster Protection - available on mobile homes with a lienholder. This coverage may increase the
         amount of dwelling coverage in order to pay off your lienholder in case of a total loss due to windstorm,
         flood, earthquake, landslide, or hail. Flood coverage must be purchased in order to add this coverage.

    -    Flood Coverage - for losses caused by or resulting from the peril of flood or rising water.

    -    Golf Cart Coverage - provides direct, sudden and accidental coverage for golf carts.

This notice provides a list of the types of additional coverages that are available. Contact your insurance company,
insurance producer or insurance agent to discuss these optional coverages.

MA930-0107                                                                                                 Page 1 of 1

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