117 Neshaminy Road
P.O. Box 330
Croydon, PA 19021
1-800-523-5686

NMLS # 129460

Manufactured Home Insurance Application

Or download the PDF version, complete and return to us by FAX 215-781-3715 or 215-781-3716;
or MAIL 117 Neshaminy Road, P.O. Box 330, Croydon, PA 19021

* = Required

USE TYPE (choose one) *

Primary Residence

Primary Farm/Ranch
(Applies to primary use risks
when Farm/Ranch operations
exceed Hobby Farm definition)

Secondary Residence

Rental
(Renter's personal property
& liability)

INSURED INFORMATION - OWNER OCCUPIED * Insured Type:

If individual is selected, complete Individual First Named Insured information. For all others, complete both Individual with Control and Entity that appears on the title or deed.

INSURED TYPE - INDIVIDUAL - Including Tenant

*Last Name:

*First Name:

*MI:

*E-mail:

*Date of Birth:

Year

Second Insured

Last Name:

First Name:

MANUFACTURED HOME LOCATION ADDRESS

(Coverage available in these states: Delaware, Maryland, New Jersey, New York, Pennsylvania and South Carolina)

*Is home located inside incorporated city limits? Yes No

*Is home in park/community? Yes No

Park Community Name:

Lot Number:

Street Address:

City:

State:

Zip:

County:

MAILING ADDRESS

*Same as location address? Yes No

If no, provide additional information below.

Street Address:

City:

State:

Zip:

*Home Phone:

*Business Phone:

*Best to Contact:

MANUFACTURED HOME INFORMATION

*Does the manufactured home or other structure have a woodstove or fireplace?

MANUFACTURED HOME INFORMATION - N/A TENANT USE

*Model Year

*Width

*Length

*Manufacturer

*Serial Number

*Manufactured Home Tied Down? Yes No

*Date of Purchase

*Purchase Price

ADDITIONAL INTEREST

*Name Line 1 or Lienholder code (if assigned)

Name Line 2

*Address Line 1

Address Line 2

*City

*State:

*Zip

INDICATE INSURABLE INTEREST:

Comments:

Any theft or liability loss greater than $2,500? Yes No	Any water loss with unrepaired damage? Yes No
Any water related losses greater than $5,000? Yes No	Two or more water losses from same cause? Yes No
Fire loss of any kind? Yes No	Three or more losses of any kind? Yes No

Manufactured Home Insurance Application

(Coverage available in these states: Delaware, Maryland, New Jersey, New York, Pennsylvania and South Carolina)

If answer to question 1 is yes, answer any additional required questions.

INDICATE INSURABLE INTEREST:

If answer to question 1 is yes, answer any additional
required questions.