Being Non-Renewed on your Policy for your Mobile/Manufactured Home?

Mobile/Manufactured Home Non-Renewal Form

Owner and Property Information

Name of Owner:(Required)

First Last

Policy Number being Non-Renewed:(Required)

Any Other Owners? (Spouse or Other):(Required)

Other Named Insureds:(Required)

Applicant Email Address:(Required)

Applicant Phone Number:(Required)

Is there a Trust?:(Required)

Name of the Trust:(Required)

Address of Home to be Insured:(Required)

Street Address City State ZIP Code

Mailing Address:(Required)

Same as Address of Home to be Insured

Street Address City State / Province / Region ZIP / Postal Code Country

Damages and Claims

ANY Claims in the Last 5 years?:(Required)

Did you File a Claim?:(Required)

Is the Claim Open or Closed?:(Required)

Did you Experience Flood Damage?:(Required)

Height of Water (In Feet or Inches):(Required)

Is all Flood Damage Repaired?:(Required)

Is There Unrepaired Damage to the Property?:(Required)

What Items were Damaged?:(Required)

What Items are Unrepaired?:(Required)

Did you Hire an Attorney for the Claim?:(Required)

Did you Hire a Public Adjuster?:(Required)

Amount Paid by Insurance Company for Claim:(Required)

Upgrades or Replacements

Were any Attached Structures updated, such as Converting a screen room to Vinyl or Glass Windows? (Weather Tight Room, Enclosed Carport, or any other Custom Updates):(Required)

Please Specify the Updated Structures:(Required)

Any Other Updates or Upgrades:(Required)

Please Specify the Updates or Upgrades:(Required)

Has your Roof ever been Replaced:(Required)

What year was your roof fully REPLACED, not just repaired?:(Required)

What is the Material of the Roof?:(Required)

Do you have an Attached Shed? (Under Carport, etc.):(Required)

Do you have a Detached Shed (In the Back or Side Yard):(Required)

Do you have a Carport?:(Required)

Do you have a Garage?:(Required)

Number of Weather Tight Rooms (Glass or Vinyl Windows):(Required)

Number of Screen Rooms (If Any):(Required)

Is there Polybutylene or "Gray" Pipes in any of your Plumbing Lines:(Required)

Click here for a Polybutylene Example and Related Information

Has the Electric Panel ever been Replaced?:(Required)

Year of Electric Panel Replacement:(Required)

Rental and Other Information

Is the Home ever Occupied by Anyone other than you (Such as a Tenant or Short-Term Rental like AirBnB or VRBO):(Required)

About how many Times a year is the Property Rented to Others:(Required)

Shortest Rental Period for Property:(Required)

How Many Months do you Occupy the Home Each Year?:(Required)

Do you have any Animals?:(Required)

What kind of Animal?:(Required)

Number of Dogs:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Do you have any Other Animals?:(Required)

What kind of Animal?:(Required)

Number of Cats:(Required)

What Other Animal(s) (Please Specify):(Required)

Number of Cats:(Required)

Do you have any Other Animals?:(Required)

What kind of Animal?:(Required)

Number of Dogs:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

What Other Animal(s) (Please Specify):(Required)

Do you have any Other Animals?:(Required)

What kind of Animal?:(Required)

Number of Dogs:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Dog Breed:(Required)

Specify Other:(Required)

Number of Cats:(Required)

Do you have a Mortgage?:

Mortgage or Bank Name:(Required)

Loan Number:(Required)

Address of Lender:(Required)

Street Address Address Line 2 City State ZIP Code

Do you have a Golf Cart?:(Required)

Is it Street Legal With a License Tag:(Required)

Year:(Required)

Make:(Required)

Model:(Required)

Value:(Required)

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