CHECK PROGRAM APPLICABLE
All Purpose (48)
ARIZONA MOBILE HOME APPLICATION
PRINT OR TYPE ALL INFORMATION
POLICY #: ___________________________
(Check box if additional Applicant / Owner is indicated in “Remarks” section on reverse side.)
SOCIAL SECURITY NO.:
DATE OF BIRTH
HOME PHONE: ( ) -
WORK PHONE: ( ) -
LOCATION ADDRESS (If different than mailing address)
NAME OF MOBILE HOME PARK
(Check box if additional Lienholder is indicated in “Remarks” section on reverse side.)
PERIOD OF INSURANCE (12:01 A.M. STANDARD TIME)
NO. OF MONTHS
DESCRIPTION OF MOBILE HOME/TRAVEL TRAILER
DATE PURCHASED PURCHASE PRICE
PHOTOS REQUIRED ON ALL OUT OF PARK OR 1976 AND OLDER UNITS
1. How long has insured lived in a mobile home? _______________________
2. Is mobile home skirted?
3. Woodstove? (If yes, complete inspection report, #A6000M0493.)
4. Tied Down?
, Vinyl Siding
, Hard Board
6. Check the applicable box(es) of those items in operable condition:
7. Has insured reported any claim in past 36 months?
8. Has insured reported any claim in past 12 months?
9. Does insured/tenant own any dogs or livestock?
10. Canceled or nonrenewed in past 36 months?
11. Is the mobile home located in an area subject to flood (or on a site which has
flooded in the past 10 years), mudslides, brush fires, or high crime?
12. Is there a swimming pool, spa, jacuzzi, trampoline or other hazard located on
13. Handrails on all stairways?