Applicant Full Name Applicant Address City, State, Zipcode Business Phone Number Home Phone Number E-Mail Address Mobile Home Year Make Model Is the mobile home tied down? Yes No Is the mobile home skirted? Yes No Are there any room additions added to this home? Yes No Are you in a mobile home park of more than 26 mobile homes? Yes No Is mobile home located on more than one acre? Yes No Is your mobile home presently insured? Yes No If yes, Insurance Company: Renewal Date: What is the current market value? What is replacement cost? Have you had ANY loss within the last three years? Yes No If yes, please list losses: Date Type of Loss Amount Paid By Ins. Co. Do you have replacement coverage on your home? Yes No Do you have replacement coverage on your personal contents? Yes No What are your liability limits? What is your deductible?