AMERICAN RELIABLE INSURANCE COMPANY
Rated "A-" Excellent BY A.M. BEST
Texas Mobile Home Owners Insurance Application
To Get Underwriting Guidelines, Territories , & Rate
Tables Click Here
Select
Policy Coverage Type:
Comprehensive
Coverage
Named
Perils Coverage
Special Mobil Home Owners Policy Form L.O.B. 37
Rental and Commercial Unit L.O.B. 48 Policy Form
Basic Policy Form LOB37 Includes The Following Deductibles /
Coverages - See Below Chart :
Territory
Deductible
Unattached Adjacent Structures
Unscheduled
Personal
Effects
ACV Claim
Settlement
Personal Liability
Medical Payments
Flood Insurance
1
$
250 All Other Perils - Except
Wind,
Hurricane, and Hail Excluded
$ 500 Lessor
Of Amount Shown In Rate Table Or $ 12,000 Maximum Limit
$ 50,000
$ 500
NONE
2
$
250 All Other Perils - Except
$ 1,000 Wind, Hurricane, and Hail
$ 500 Lessor
Of Amount Shown In Rate Table Or $ 12,000 Maximum Limit
$ 50,000
$ 500
Agreed Value Included
3
$
250 All Other Perils - Except $ 500
Wind, Hurricane, and Hail
$ 500 Lessor
Of Amount Shown In Rate Table Or $ 12,000 Maximum Limit
$ 50,000
$ 500
Agreed Value Included
4
$
250 All Other Perils - Except $ 500 Wind,
Hurricane, and Hail
$ 500 Lessor
Of Amount Shown In Rate Table Or $ 12,000 Maximum Limit
$ 50,000
$ 500
Agreed Value Included
5 **
$
250 All Perils - Except $ 500 Wind, Hurricane,
and Hail
$ 500 Lessor
Of Amount Shown In Rate Table Or $ 12,000 Maximum Limit
$ 50,000
$ 500
Agreed Value Included
6 **
$
250 All Perils - Except $ 500 Wind, Hurricane,
and Hail
$ 500 Lessor
Of Amount Shown In Rate Table Or $ 12,000 Maximum Limit
$ 100,000
$ 500
Agreed Value Included
7
$
250 All Other Perils $ 500 Hail
10 % Of Dwelling Limit Lessor
Of Amount Shown In Rate Table Or $ 35,000 Maximum Limit
$ 100,000
$ 500
Agreed Value Included
8
$
250 All Other Perils $ 500 Wind, Hail, Flood
10 % Of Dwelling Limit Lessor
Of Amount Shown In Rate Table Or $ 35,000 Maximum Limit
** Dallas, Johnson, Parker , Tarrant
Counties : $ 250 AOP $ 500 Wind & Flood
$ 1,000 Hail
***See
Coverage Options
Section Below To Select Replacement
Cost Claim Settlement - Liability Increased Limits - Or Additional
Coverages
NAMED INSURED
PRODUCER
Name
Agent Name Tx Agent
License
#
Address
REQUEST POLICY TERM
City
State
Zip
From
County
Phone No.
Time
AM PM
Occupation
Employer
BINDING COVERAGE: For coverage to begin as requested, the
application must be fully completed and signed within 48 hours of the
requested
effective date. Otherwise, coverage is bound at 12:01 a.m.
the
day the application is received by American Reliable Insurance Company.
Email
Address
Social Security
Num.
DOB
Spouse Name
Spouse SSN
DOB
Spouse Occupation
Employer
BILLING / ACCOUNTING INFORMATION
Additional Insured
Bill To:
Insured
Lien
Holder
Address
Check #
Check Amount
City
State
Zip
LOCATION
LIEN HOLDERS
Park Name
1st
Name
Address, if
different then above (include county and zip)
Address
City
Distance of unit to
fire hydrant
feet
State
Zip
Loan #
2nd
Name
Distance of unit to
responding fire station
miles
Address
Is mobile home
located inside city limits?
?
No
Yes
City
STATE
ZIP
LOAN #
DESCRIPTION OF MOBILE HOME ADDITIONS AND UNATTACHED STRUCTURES
Year
Manufacturer
Length
Width
Serial Number
Purchase Date
Purchase Price
Current
Value
Describe
Additions/Attached Structures
Age
Describe Unattached
Structures
Age
GENERAL INFORMATION
POLICY INFORMATION
Rate Territory
(If You Do Not Know Leave Blank - We Will Look Up )
Select
1
2
3
4
5
6
7
8
COVERAGES
COVERAGE
LIMITS
Usage
Select
Primary
Seasonal
Rental
Commercial
Mobile Home and
Additions
If RENTAL, is Mobile Home currently occupied by tenant?
No
Yes
Unattached
Adjacent Structures
Protection
Class (Fire District Protection Rating -
If You Do Not Know Leave Blank - We Will Look Up )
?
1
2
3
4
5
6
7
8
9
10
Personal Effects
Personal Liability
Select
None
$25,000
$50,000
$100,000
$300,000
Year Mobile Home
Manufactured
YYYY
Medical Payments to Others
$500
Select
$1,000
None
How long has
insured lived in the Mobile Home?
Deductible
Select
$250 All Perils
$250 AOP with $ 1,000 Wind-Hail
$500 All Perils
$500 AOP with $ 1,000 Wind-Hail
$1,000 All Perils
Prior Insurance
No
Yes
New
Purchase
Territory 1 - Wind, Hurricane and Hail
Excluded
Hemphill Insurance Agency will provide Texas Windstorm Insurance Pool (TWIP) Quote.
Prior Company &
Policy #
*** Coverage Options
Supplemental
Heating
Select
None
Woodburning Stove
Fireplace
Other
If other
Select
Optional Coverage Requested
Owner and Landlord Liability For Rental Units Rented To Others
None
$25,000
$50,000
$100,000
Wood, Masonite or
Vinyl Siding
No
Yes
Satellite System
-
Limit $5,000
Additional
Premises Liability
No
Yes
+
Animals on
Premises
No
Yes
Breed of Dog
Number of Secondary Residences
?
1
2
3
4
Type of Animal
Number Rented to
Others
?
1
2
3
4
Replacement Cost On Personal Effects
RATE $0.30 Per $ 100 Of
Coverage
$ 25 Minimum Premium Applies
Yes
No
Park Status
In
a Park
# of spaces
Lien Holders - Lenders Interest
Rate $ 15
No
Yes
Out
of Park
# of acres
Enhancement Coverage
- Increases Add'l Living Expense /Debris Removal /
Emergency Removal/Fire Service Charge/Radio & TV Antenna/
Treee-Shrubs-Plants-Lawns,Tie Down,Claims Expenses/Damage To Others
Property -
Rate $ 20
Yes
No
Full Time Onsite
Park Manager?
No
Yes
Supplemental
Heating Surcharge
- Add $40
Yes
No
Scheduled Personal Property
Delete Flood
Coverage
- Subtract $ 35.00
No
Yes
List Scheduled Personal Property -
Yes
No
COVERAGE
LIMIT REQUESTED
Lien Holders
Natural Disaster Coverage
Rate $ 5
No
Yes
1.
Golf Cart $100
Deductible
Rate $ 35
No
Yes
2.
30 Day Trip Coverage To
Move Unit $100
Deductible
Rate $ 50 S . Wide
$ 100 Double Wide
No
Yes
Select
Single Wide
Double Wide
3.
Trip Date
4.
Mobile Home
Replacement Cost
Available To Units 0-10 Years Old
Rate $ 10
Yes
No
5.
6.
Rates Shown Above Are
For Special L.O.B 37 Only
7.
8.
9.
10.
11.
Totals
$
RATE $2.50 Per $ 100 Of Coverage
PROPERTIES WITH HIGHER THAN AVERAGE RISK FACTORS
If Any Question
1 through 6 Below Is Answered " Yes " Hemphill Insurance Agency Will
Submit An Application To Another Non-Standard Surplus Lines Insurance
Carrier.
1.
Does the home have
existing structural damage or has it been salvaged?
?
No
Yes
2.
Is the home
vacant, under construction/major renovation or in foreclosure?
?
No
Yes
3.
Does the home have
a kerosene heater or heat reclaiming device?
?
No
Yes
4.
Does the home have
a wood, coal or pellet burning device that is used as the primary source
of heat?
?
No
Yes
5.
Is there any
childcare, homecare, lodging, auto repair or chemical processing
conducted on the premises?
?
No
Yes
6. :
Does the applicant own, keep, or shelter any of the following animals
breeds
his includes but
is not limited to Akitas, Chows, Dobermans, Great Danes, Pit Bulls, Rottweiler's,
Anatolian Shepherds, Wolfs or Wolf Hybrids, any mix of these breeds, any
animal with a previous bite history or any exotic (snakes, monkeys,
etc.) animals?
nimal
Liability Limitation is attached. The maximum liability limit for the
policy is $10,000.)
?
No
Yes
RISKS WITH EXPOSURES LISTED BELOW MAY BE ELIGIBLE FOR COVERAGE
WITHOUT LIABILITY
1.
Is there a
swimming pool or jacuzzi on the premises that does not have a four-foot
fence with a self-latching gate or a swimming pool that has a diving
board or slide?
?
No
Yes
2.
Is there a
trampoline on the premises?
?
No
Yes
3.
Is there a dock,
pier or boathouse on the premises?
?
No
Yes
4.
Is the home
without permanently installed steps at all entrances?
?
No
Yes
STANDARD RISKS - SUBMIT FOR UNDERWRITING REVIEW & APPROVAL
Any "Yes" Response Must Be Explained Below
1.
Has the applicant
had 2 or more property losses in the past 3 years or any single fire,
theft, liability or flood loss in the past 3 years? If yes, give date of
loss, describe the loss and the amount paid to repair the damage.
?
No
Yes
2.
Has the applicant
had a mobile home/dwelling policy cancelled or non-renewed for
underwriting reasons (except age of unit) during the past 3 years?
?
No
Yes
3.
Has the applicant
filed for bankruptcy in the past 3 years?
?
No
Yes
4.
Has the applicant
been delinquent in mortgage payments in the past year?
?
No
Yes
5.
Has the applicant
been uninsured for more than 30 days immediately prior to the requested
effective date? (Not applicable to new purchases)
?
No
Yes
6.
Does the home have
an open foundation or is it built on stilts, posts or piers? Photos must
be included.
?
No
Yes
7.
Are there any
structures or section(s) of the home, other than porches, decks,
awnings, skirting or carports, that are not factory/contractor built or
two separate homes that are joined together? Photos must be included.
?
No
Yes
8.
Does the home have
a supplemental heating device that was not installed by the manufacturer
or a licensed contractor? Photos must be included and Woodstove
Inspection must be included.
?
No
Yes
9.
Is the home
located in a Special Flood Hazard Area or island or within 1,500 feet of
water (lake, pond river, ocean or creek (excluding reservoirs)?
?
No
Yes
10.
Are there any
horses, livestock or farm animals on the premises?
?
No
Yes
11.
Does the premises
have 5 or more acres?
?
No
Yes
12.
Is there any
business or farming activities conducted on the premises?
?
No
Yes
13.
Does the home have
3 or more steps on any exit without a handrail? Photos must be included.
?
No
Yes
Explain "Yes"
answers!
FAIR CREDIT REPORTING ACT NOTICE:
In compliance with the Federal Credit Reporting Act (Public
Law 91-508), you are advised that the Company may order
reports, which may contain or include information pertaining
to the character, general reputation, personal
characteristic, and mode of living of the applicant and/or
other drivers listed in this application. Upon written
request, the complete nature and scope of the investigation
will be provided.
FRAUD WARNING:
Any person who knowingly and with intent to
defraud any insurance company or other person files an
application for insurance or statement of claims 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 may subject such person to criminal and
civil penalties.
PRIVACY POLICY:
I have received and read a copy of the
American Reliable Insurance Company/Assurant
Group Privacy Policy. By submitting this application, I am
applying for insurance and, at its expiration, for
appropriate renewal policies issued by American Reliable
Insurance Company. I understand and agree that any
information about me that is contained in, or that is
obtained in connection with, this application of any policy
issued to me may be used by American Reliable Insurance
Company to issue, review, and renew the insurance for which
I am applying.
I hereby declare to the best of my knowledge
and belief that all of the foregoing statements are true and
these statements are offered as an inducement to the Company
to issue the policy for which I am applying. I understand
this policy may be cancelled if this application contains
any false statement, omission, or material misrepresentation
that would have otherwise altered the company's evaluation
of the named insured. I understand that motor vehicle
records may be verified.
Insured's E-Signature
(Enter Full Name Of Person Who Completed
Above Application )
Date Above Application Completed
