MOBILE HOME PARK APPLICATION - Travelers
MOBILE HOME PARK APPLICATIONProposed First Named Insured & Other Named Insured(s): FORMTEXT ?????Mailing Address StreetCityCountyStateZIP Code FORMTEXT ?????Park Address StreetCityCountyStateZIP Code FORMTEXT ?????Telephone: FORMTEXT ?????Fax: FORMTEXT ?????Contact Person/Phone #: Inspection: FORMTEXT ?????Accounting/Records: FORMTEXT ?????Business Type: FORMCHECKBOX Individual FORMCHECKBOX Partnership FORMCHECKBOX Corporation FORMCHECKBOX LLC FORMCHECKBOX Trust FORMCHECKBOX Other (specify): FORMTEXT ?????Date Business Established: FORMTEXT ?????Years Under Current Ownership: FORMTEXT ?????Effective Date Desired: From: FORMTEXT ?????To: FORMTEXT ?????Term Desired: FORMTEXT ?????PREVIOUS INSURER & LOSS HISTORY – Attach separate sheet if necessary FORMCHECKBOX See Loss Runs AttachedMissouri Applicants: DO NOT answer this question.Has insurance of this type been cancelled, refused, or nonrenewed by any company during the past 3 years? FORMCHECKBOX No FORMCHECKBOX Yes - If Yes, give name of company, date, and reason: FORMTEXT ?????Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the past 3 years:PolicyDatesCarrierPolicy NumberCoveragePremium FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Provide the following information for all claims, suits, or incidents which may give rise to a claim for the past 5 years.DatesMonth/YearDescription of LossAmountPaidReserve FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DESIRED TERMS AND CONDITIONS1.Coverage desired: FORMCHECKBOX General Liability FORMCHECKBOX Hired & Non-Owned Auto2.General Liability – Limit of Liability Desired: FORMCHECKBOX $100,000/$200,000 FORMCHECKBOX $300,000/$600,000 FORMCHECKBOX $500,000/$1,000,000 FORMCHECKBOX $1,000,000/$2,000,000 FORMCHECKBOX Other: FORMTEXT ?????Note: Standard coverage includes the following:Damage to Premises Rented to You$100,000Medical Payments$1,000Personal and Advertising InjurySame as Occurrence Limit3.Stop Gap Liability: FORMCHECKBOX $300,000 FORMCHECKBOX $500,000 FORMCHECKBOX $1,000,0004.Hired & Non-Owned Auto: FORMCHECKBOX $300,000 FORMCHECKBOX $500,000 FORMCHECKBOX $1,000,000(Complete Supplemental Application)5.Does the applicant desire Assault or Battery coverage? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, has there been or are there currently any allegations, incidents, losses or claims for assault or battery? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide details: FORMTEXT ?????OPERATIONS1.Occupancy – Check all that apply and show % of each: FORMCHECKBOX Retirement FORMTEXT ?????% FORMCHECKBOX Adults Only FORMTEXT ?????% FORMCHECKBOX Family FORMTEXT ?????% FORMCHECKBOX Camp Ground FORMTEXT ?????%2.Type of units in the park: FORMCHECKBOX Single Wide FORMTEXT ?????% FORMCHECKBOX Double Wide FORMTEXT ?????% FORMCHECKBOX Campers FORMTEXT ?????% FORMCHECKBOX Travel Trailer FORMTEXT ?????% FORMCHECKBOX Modular FORMTEXT ?????%3.Average vacancy rate: FORMTEXT ?????%4.Number of rental units, by age, of home:1-5 years FORMTEXT ?????6-10 years FORMTEXT ?????11-15 years FORMTEXT ?????Over 15 years FORMTEXT ?????5.6.7.8.Do you require tenants to carry Homeowners insurance?Indicate if you or your manager lives in the Park: FORMCHECKBOX Owner FORMCHECKBOX ManagerIs manager a full-time employee?Do you allow pets? If yes, answer the following questions:a. FORMCHECKBOX Less than 20 lbs. FORMCHECKBOX More than 20 lbs.b.Any bite incidents in the past 5 years?c.Any breeds such as Doberman, Pit Bull, Rottweiler, Chow, or wolf hybrids allowed?d.Are all dogs registered with park management?e.Does the park require a copy of Homeowners insurance?f.Are all dogs required to be on a leash?YesNo FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX RECREATIONAL EXPOSURES1.2.Indicate if the following are present by checking the box below: FORMCHECKBOX Aerobics/Fitness Classes or Weight Room FORMCHECKBOX Tours/Shuttle Service FORMCHECKBOX Sauna/Spas FORMCHECKBOX Tenant Garage Sales/Flea Market FORMCHECKBOX Hobby Shops or Hobby Classes FORMCHECKBOX Shuffle Board FORMCHECKBOX Activities Involving AnimalsIs any of the following open to the public?a.Laundry Facilities FORMCHECKBOX Yes FORMCHECKBOX Nob.Tennis Courts FORMCHECKBOX Yes FORMCHECKBOX Noc.Swimming Pool FORMCHECKBOX Yes FORMCHECKBOX Nod.Playground FORMCHECKBOX Yes FORMCHECKBOX NoIndicate Type of surface: FORMTEXT ?????3.List other activities not mentioned above: FORMTEXT ?????4.5.Is facility used by the public for meetings, weddings, church, etc.? FORMCHECKBOX Yes FORMCHECKBOX NoAre there any functions or activities where alcoholic beverages are served or permitted? FORMCHECKBOX Yes FORMCHECKBOX NoSUBCONTRACTED WORK1.Do you subcontract work to others (such as carpentry, security, premises maintenance, etc.)? FORMCHECKBOX Yes FORMCHECKBOX Noa.Type of work: FORMTEXT ?????b.Cost of subcontractor’s contract labor: $ FORMTEXT ?????2.Are subcontractors required to carry insurance? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, indicate coverage and limits: FORMTEXT ?????3.Are certificates of insurance required from subcontractors? FORMCHECKBOX Yes FORMCHECKBOX NoPARK UTILITIESTrash/Garbage FORMCHECKBOX City FORMCHECKBOX Park providesElectric FORMCHECKBOX Public Utility FORMCHECKBOX Park providesWater FORMCHECKBOX Public Utility FORMCHECKBOX Park/WellSewer/Septic FORMCHECKBOX Public Utility FORMCHECKBOX Park providesRoads FORMCHECKBOX Public maintains FORMCHECKBOX Park maintainsGas FORMCHECKBOX Public (tenant pays utility co.) FORMCHECKBOX Park providesGENERAL INFORMATION1.2.Are there formal written and enforced park rules? FORMCHECKBOX Yes FORMCHECKBOX NoTotal capacity of park: FORMTEXT ?????3.Number of sites rented to others: FORMTEXT ?????Number of vacant sites: FORMTEXT ?????4.Number of units rented to others: FORMTEXT ?????Number of vacant rental units: FORMTEXT ?????5.Total annual receipts: $ FORMTEXT ?????6.7.8.9.Tenancy annual turnover rate: FORMCHECKBOX Less than 10% FORMCHECKBOX More than 10%Surface area of streets: FORMCHECKBOX 100% paved FORMCHECKBOX Partially paved FORMCHECKBOX Not pavedStreet lighting: FORMCHECKBOX Complete FORMCHECKBOX Partial FORMCHECKBOX NoneIs there any real estate development? FORMCHECKBOX Yes FORMCHECKBOX Noa.Number of acres: FORMTEXT ?????b.Type of development: FORMTEXT ?????10.Is there any vacant land? FORMCHECKBOX Yes FORMCHECKBOX Noa.Number of acres: FORMTEXT ?????b.Is it used as a landfill or dump? FORMCHECKBOX Yes FORMCHECKBOX Noc.Does a water exposure exist? FORMCHECKBOX Yes FORMCHECKBOX No11.Do you own or operate any other business at this location? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe: FORMTEXT ?????12.Do you sell new or used units? FORMCHECKBOX Yes FORMCHECKBOX No Annual Gross Sales: $ FORMTEXT ?????13.Do you sell, service or distribute LP/Natural Gas? FORMCHECKBOX Yes FORMCHECKBOX NoNumber of gallons: FORMTEXT ?????Receipts: $ FORMTEXT ?????14.Do you sell or store gasoline? FORMCHECKBOX Yes FORMCHECKBOX NoNumber of gallons: FORMTEXT ?????Receipts: $ FORMTEXT ?????15.Number of police calls or visits during the past year: FORMTEXT ?????16.Are there any signs of criminal, drug, or gang activity on or near the insured properties? FORMCHECKBOX Yes FORMCHECKBOX NoConsult for activity.Swimming Pools1.2.3.4.5.6.7.8.9.Number of swimming areas: FORMTEXT ?????Is the pool completely fenced, with self closing, self locking gates?Are depths marked?Maximum depth FORMTEXT ????? ft.Is standard safety equipment provided?Is there a diving board or platform?Is there a water slide of any kind?Is there a Jacuzzi, hot tub or spa?Are rules and emergency numbers posted?Is there a lifeguard on duty at any time?If no, is there a sign posted “No Lifeguard on Duty – Swim At Your Own Risk”?YesNo FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OTHER WATER EXPOSURES1.Are there any water exposures (other than swimming pools) on your property?If yes, describe: FORMTEXT ?????YesNo FORMCHECKBOX FORMCHECKBOX 2.3.Can it be used for swimming?Are “No Swimming” signs posted? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4.5.Is it used for boating or fishing?Is there a marina on the premises?If yes, are you the operator?YesNo FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6.Are there docks or slips? If yes: FORMCHECKBOX FORMCHECKBOX a.Do you charge a fee?If yes, annual receipts: $ FORMTEXT ?????b.Do you or any employee handle the boats? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX RENTAL UNITS – COMPLETE IF APPLICABLE1.Indicate how rental units were acquired: FORMCHECKBOX Purchased new from dealer FORMCHECKBOX Purchased used from dealer FORMCHECKBOX Purchased or obtained from previous tenant (provide circumstances): FORMTEXT ?????2.Rental income per rental unit: $ FORMTEXT ?????3.Maximum occupants per unit: FORMTEXT ?????4.Frequency you inspect inside the rental units: FORMTEXT ?????5.6.Are units inspected prior to new occupancy? FORMCHECKBOX Yes FORMCHECKBOX NoFrequency of inspections, by a licensed contractor, of the heating, plumbing and electrical: FORMTEXT ?????7.8.9.Are formal maintenance records kept for each rental? FORMCHECKBOX Yes FORMCHECKBOX No If yes, attach a sample copy.Are smoke detectors present? FORMCHECKBOX Yes FORMCHECKBOX NoType: FORMCHECKBOX Hard-wired FORMCHECKBOX Battery operatedIs there a battery replacement schedule plan in place for smoke detectors? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe: FORMTEXT ?????10.11.If no, you must have a waiver/release from the tenant, accepting responsibility for battery replacement.Are fire extinguishers installed? FORMCHECKBOX Yes FORMCHECKBOX NoAre any rental units over 15 years of age? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, complete the following for each rental unit and provide photos of the front and back:Year BuiltYear UpdatedHeatingPlumbingWiringRoofing FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12.13.14.Do all rental units have skirting appropriate for manufactured housing? FORMCHECKBOX Yes FORMCHECKBOX NoAre there steps at exterior doors with properly installed handrails? FORMCHECKBOX Yes FORMCHECKBOX NoNote: Concrete block steps are not acceptable.Lease terms: FORMCHECKBOX Weekly FORMCHECKBOX Monthly FORMCHECKBOX 6 Month FORMCHECKBOX 9 Month FORMCHECKBOX 12 MonthAttach a copy of the Park rules.For information about how Northland compensates its agents, brokers and program managers, please visit this website: you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Northland Insurance Companies, c/o Law Department, 385 Washington St., St. Paul, MN 55102.This application, including any material submitted in conjunction with the application or any renewal, does not amend the provisions or coverages of any insurance policy or bond issued by Northland.? It is not a representation that coverage does or does not exist for any particular claim or loss under any such policy or bond.? Coverage depends on the facts and circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law.? Availability of coverage referenced in this document can depend on underwriting qualifications and state regulations.FRAUD STATEMENTSARKANSAS, DISTRICT OF COLUMBIA, MARYLAND, NEW MEXICO, AND RHODE ISLAND: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.COLORADO: 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.FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.KENTUCKY, NEW JERSEY, NEW YORK, OHIO, AND PENNSYLVANIA: 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. (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation.)LOUISIANA, MAINE, TENNESSEE, VIRGINIA, 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 may include imprisonment, fines, and denial of insurance benefits.IMPORTANT NOTICEDECLARATIONI DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE.As part of our underwriting procedures, a routine inquiry may be made to obtain applicable information concerning character, general reputation, and credit history. Upon your written request, additional information as to the nature and scope of the report, if one is made, will be provided.SIGNATURESApplicant SignatureTitleDateProducer SignatureDateProducer Name and Address ................
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