Holiday Trailer Application

As it should appear on Policy
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If different from postal
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12:01 a.m. Standard Time at the Postal Address of the named Insured as stated herein
1000 ft. or 305 m.
Fully Skirted?:

Mandatory: Must be fully skirted, on blocks and have tie-downs
On Blocks?:

Mandatory: Must be fully skirted, on blocks and have tie-downs
Tie-downs?:

Mandatory: Must be fully skirted, on blocks and have tie-downs
On Foundation?:

Mandatory: Must be fully skirted, on blocks and have tie-downs
Are any appliances used to aid primary heating system?:

e.g. space heaters, wood burning stoves
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Fuses :


Past 5 Years
Method of Payment:

*REMINDER: Please attache a recent, original photo of Mobile Home (including outbuildings). If Policy is on Monthly Pay; include First and Last Months Deposit, Void Check and signed Authorization Form. Brokers do not have binding authority.
Policy Type:



Mobile Home:

Content:

Principle Residence:


Comprehensive Personal Liability :


Discounts:




Maximum discounts allowed = 30% ** Discounts taken from base premium only**
Deductible Choices:

Surcharges: Auxiliary Heating Surcharge of $85:
(Additional premium of $25 applicable). Attach schedule if applicable.
(Additional premium of $25 applicable). Attach schedule if applicable.
Attach schedule if applicable.
Attach schedule if applicable.
Minimum policy premium: $150, Minimum retained: $150.
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