ACORD Forms : How to Complete a Mobile Home Application 85
The underwriting process for any personal lines policy begins with the
submission of a completed application. This guide will provide assistance in completing the ACORD Mobile Home Application.
Enter previous physical address of the first named insured if the applicant has been at the current address for less than three years. Also indicate the number of years at the previous address.
Location of Property if Diff From Above
Enter the physical address of the property to be insured only if it is different from the mailing address listed above.
Briefly describe the occupation for the applicant(s) named in the identification section. State the nature of the business if self employed.
Applicant's/Co-Applicant's Employer Name and Address
Name and address of the organization that employs the applicant(s) named in the identification section.
Yrs in Curr. Occ.
Number of years in current occupation or business.
Yrs w/Curr. Empl.
Number of years with the present employer. If less than 3 years, provide the number of years in career field or industry in the Remarks section.
Yrs w/Prior Empl.
Number of years with the prior employer.
Marital status of each named applicant. Codes:
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single
M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married
D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced
SP . . . . . . . . . . . . . . . . . . . . . . . . . . . Separated
W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed
Date of Birth
Birth date of each named applicant (MM/DD/YYYY). (E.g., March 7, 1944 should be 03/07/1944.)
Social Security #
Social security number for each named applicant.
Questions relating to agent's knowledge of applicant and when property was inspected
Indicate how long the agent has known the applicant, and the date when the property was last inspected.
Provide the following information for each entity having an interest in the mobile home(s) to be insured: the interest number or rank (1st, 2nd), whether the additional interest is the mortgage holder (e.g., bank in which the mortgage is held), or other interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number.
COVERAGES/LIMITS OF LIABILITY
List the anticipated dollar limit amounts for each applicable coverage.
Deductible & Type
Enter the deductible amount and the type (Flat, Percentage,) The deductibles may vary from one amount for all perils to different deductibles for various coverages..
Enter the name of each applicable endorsement, and the applicable limit of coverage, if any.
Enter the estimated total premium, the deposit paid by the applicant, and the balance due later.
Indicate whether the agency or the company (direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan to be used for payment.
RATING UNDERWRITING INFORMATION
The model year for the mobile home, not necessarily the year the unit was manufactured.
Make and Model
The name of the manufacturer.
The unique identification number for this mobile home.
Mobile home's exterior length and width, expressed in feet.
Year the applicant acquired the dwelling and the purchase price. The year should be expressed in YYYY format.
Check the box to indicate if the mobile home was purchased new by the applicant, or if it was purchased from a previous owner.
Check the appropriate box to show the location of the cooking equipment within the mobile home.
Check the appropriate box to indicate the type of tie down, if any, used to secure the mobile home from wind damage.
Location of the mobile home based on individual state bureau or company manual pages.
Fire Prem Group
The applicable premium group based upon the mobile home's location, construction and fire protection code. Some companies require this data; others generate it.
EC Prem Group
Extended coverage, broad form and special form premium group number determined from the territory.
Pers Liab Terr Code
Provide the territory code determined by the dwelling's location if the company's rate structure requires separate rating information for personal liability.
Four character fire protection class found in individual state manuals.
Distance to Hydrant
Distance (in ft.) from the nearest hydrant that supports the protection class used.
NOTE: Where the distane to the nearest hydrant is over 1000 feet, or there is no public hydrant, describe in Remarks any additional water source such as cisterns or water tanks.
Distance to Fire Station
Distance in miles from the nearest fire station that supports the protection class used.
Fire District/Code Number
Fire district name and corresponding code number which can be found in the individual state manual pages.
Protection Device Type
For alarms to qualify for credit, a copy of the manufacturer's specification sheet must be submitted with the application.
Type of heating device for the residence. If the residence has no heat, check the box.
If more than one type exists, indicate the primary and secondary types. Use the Remarks section if necessary. If fuel storage tanks are located on the premises, describe the type and indicate the location. Possible types include:
Electric - Permanent/Portable
Liquid Propane - Permanent/Portable
Oil - Permanent/Portable
Kerosene - Permanent/Portable
Coal - Professionally/Non-Professionally Installed
Other - Explain the heating system in Remarks section
Indicate by whom the mobile home is currently occupied: owner, tenant, no occupants, or the mobile home is vacant.
Indicate if the mobile home is the applicant's primary or secondary residence, or if the use is seasonal, or rented to others.
An evaluation of the interior upkeep of the mobile home.
Check the appropriate box.
Check the box that most closely describes the type of foundation.
Check the appropriate boxes to indicate which utilities are permanently connected to the structure.
Check the appropriate box to indicate copper or aluminum wiring, and show the date the wiring was las inspected.
Describe any other structure(s) to be included in Coverage B - Other Structures.
If the mobile home is located in a mobile home park, give Yes or No answers to the questions relating to park management and access to the park.
If the mobile home is not located in a mobile home park, give Yes or No answers to the question relating to visibility from the road.
In either case, answer the question regarding road paving.
GENERAL INFORMATION QUESTIONS
Use the remarks section to provide additional information for any questions answered with a "Yes" response.
1. Any business conducted on premises?
Describe the business as well as where the business is conducted on the premises.
2.Any residence employees?
Describe the number and type of full and part time employes.
3. Any flooding, brush hazard, fire hazard, landslide, etc.
Use the Remarks section to describe the type of hazard and the distance between the residence and the hazard. Some companies may require a photograph.
4. Any other residence owned, occupied or rented?
Use the Remarks section to detail the occupancy or use of the other residence. If no liability coverage is requested for this residence, detail where the coverage is provided if liability coverage is to be included in the policy for any property.
5. Any other insurance with this company?
Indicate whether other insurance is currently written for this applicant by the company.,If a submission was mailed to another department recently, note it in the Remarks section along with any policy numbers available.
6. Has insurance been transferred within the agency?
Indicate why the insurance has been moved from the last company.
7. Any coverage declined, cancelled or non-renewed?
Explain the circumstances surrounding the situation. This question cannot be asked in certain states.
8. Has applicant had a foreclosure, repossession or bankruptcy during the past five years?
Use the Remarks section to provide information regarding any real estate foreclosure, personal property repossession, or bankruptcy filing during the specified time period.
9. Are there any animals or exotic pets kept on the premises?
Use the remarks section to give the age, breed, or other information about livestock or pets that may be vicious or dangerous to human beings. Also give any history of biting or causing injury to others.
10. Is property located within two miles of tidal water?
Use the Remarks section to describe the coastal hazard, if applicable.
11; Is property situated on more than five acres?
Ust the Remarks section to indicate if any part of the property is farmed, or used to grow crops or animals for sale, or used for any other non-residential purpose.
12. Does applicant own any recreational vehicles (snowmobiles, dune buggys, ATVs, mini-bikes, etc.)?
Use the Remarks section to describe the recreational vehicle. Include the year, type, make, model, and any other information necessary to provide a complete description.
13. During the last five years (ten in RI), has any applicant been convicted of any degree of the crime of arson? (In Rhode Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.)
Rhode Island law requires that all applicants for property insurance must answer this question.
14. Any uncorrected fire or building code violations?
Describe any violations of applicable codes that have not been corrected.
15. Is mobile home for sale?
Provide the length of time the mobile home has been for sale, and the expected sale date, if known.
16. Is property within 300 feet of a commercial or non-residential property?
Describe the occupancy of any commercial or non-residential property.
17. Is there a trampoline on the premises?
Describe the device.
18. Any lead paint hazard?
Describe the location and the extent of the hazard.
19.If a fuel oil tank is on the premises, has other insurance been obtained for the tank?
Give the First Party to the insurance and the applicable limit, and the Third Party and the applicable limit.
20. Is home doublewide construction?
Indicate if the mobile home is doublewide construction.
This section shows the losses this applicant has had in the past. List losses for the last three years unless the company requires a different period of time.
Provide the prior insurance company's name.
Prior Policy Number
List the complete policy number including prefix and suffix.
Provide the expiration date of the prior insurance policy.
Labels: Mobile Home Application 85