MOBILE HOME APPLICATION

Client Details

Client 1.

Full Legal Name:

Date of Birth:

Phone:

Email

Client 2.

Full Legal Name:

Date of Birth:

Phone:

Email

Client 3.

Full Legal Name:

Date of Birth:

Phone:

Email

Client 4.

Full Legal Name:

Date of Birth:

Phone:

Email

Location Address:

Mailing Address (if different):

Name of Mobile Home Park (if applicable):

Additional Named Insured (ANI):

Union MemberYesNo

If Applicable, provide details:

Previous Address ( If resided at current residence for less than 3 years )

Previous Address:

How many years have you resided at this address at:

How did you hear about us?

Previous Insurance History

Insurer Name:

Policy #:

Effective Date:

Expiry Date:

Any claims in the last 5 years? YesNo

If yes, provide detail:

Any claims that you are aware of at the new location? YesNo

If yes, provide detail:

Have you ever been cancelled, refused, or declined insurance? YesNo

If yes, provide detail:

*If Applicable

Effective Date:

Subject Closing Date:

Insured Since:

Property Insured Since:

Possession Date:

Move in Date:

Insured with Broker Since:

Occupied Since:

Mortgage / Credit Consent

Mortgage: YesNo

Credit Consent:YesNo

Consent:VerbalWritten

Number of mortgages / secured lines of credit:

Name of financial institution:

Mobile Home / Manufactured Details

Year Built:

Manufacturer:

Model:

Serial Number:

Single Wide:YesNo

Double Wide:YesNo

Width:

Height:

Purchase Price:

Content Value:

# of smoke detectors:

Garage: NoneAttachedBuilt-in

# of cars:

Any decks or porches:YesNo

If yes, Size:

Any additions:YesNo

If yes, Size:

Is it fully skirted:YesNo

Roof:Asphalt ShinglesClay TileAluminiumSteelWood ShakeTar and GravelTorch on Membrane

Any Custom Features:

Fire Protection

Within 300m of a fire hydrant:YesNo

Within 8km of responding fire hall:YesNo

Heating

Primary Heat Type: —Please choose an option—Central furnaceBaseboardsCeiling radiantIn-floor radiantWoodstoveWood InsertPellet Stove

If Central Furnace, type: Natural GasElectricPropaneWoodOil

If woodstove or wood insert, # of cords burned annually:

Year primary heat was updated:

Auxiliary Heat Type (if applicable): —Please choose an option—WoodstoveWood insertPellet stove

# of cords burned annually (if applicable):

How often is chimney cleaned:

Professionally Installed: YesNo

WETT Certified: YesNo

Year auxiliary heat was updated:

Oil Tank (if applicable)

Location: InsideOutsideIn-groundAbove ground

Tank information: Single wallDouble wall

Year manufactured:

Electrical

—Please choose an option—CopperAluminumKnob and tubeOther

If other, provide details:

BreakersFuses

Amps: 60 amp100 amp200 amp

Other:

Year of any updates to electrical:

Plumbing

Type:
CopperPolybutylene (poly8)GalvanizedPEXPVCOther, please describe

Describe Other if selected

Hot Water: TankOn demand

Hot water tank age:

Does the home have a boiler? YesNo

Year of any plumbing updates:

Sewer: SepticCity sewer

Water Prevention Sump pump and/or Back flow valve

Sump pump: YesNo

Aux. power: PedestalSubmersibleFloor suckerWater powered

Back flow valve: YesNo

If yes: GateFlapper

Additional Questions

Is the dwelling under construction / renovations? YesNo

If yes, provide additional information:

Vacant: YesNo

If yes, provide additional details

How long has it been vacant?

How long do you expect it to be vacant?

Number of families living in the home:

Any: Rental suitesRoommatesBordersStudents

If yes, provide additional information:

Rental Income $:

Landlord contents $:

Home Base Business:

YesNo

Name of business:

Type of business:

Clients visit home: YesNo

Do you have a current CGL: YesNo

Website:

Any farming on premises YesNo

Other

Pool:YesNo

If yes: In groundAbove ground

Hot tub:YesNo

Trampoline: YesNo

Dock and/or Wharf: YesNo

Earthquake coverage required:YesNo

Number of cannabis plants grown on premises:

Monitored burglary alarm: YesNo

Interior sprinkler system in your unit: YesNo