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                                                               Texas Mobile Home Owners Insurance Application

  To Get Underwriting Guidelines, Territories , & Rate Tables Click Here  Need help understanding underwritng questions , rules, or rate tables call 1-800-361-8734 !

       Need help with this question call 1-800-361-8734 !   Select Policy Coverage Type:   


                                     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

$ 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

$ 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

$ 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

$ 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

$ 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

$ 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


Name   Agent NameTx Agent License  #
City State Zip   From        
County Phone No.   Time    
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  
Additional Insured   Bill To:          
Address   Check #

Check Amount

City   State Zip    
Park Name 1st Name
Address, if different then above (include county and zip)   Address
Distance of unit to fire hydrant feet     State  
    Loan #
    2nd Name
Distance of unit to responding fire station   miles   Address
Is mobile home located inside city limits?     City  
        LOAN #  
Year Manufacturer Length Width Serial Number Purchase Date Purchase Price Current Value
Describe Additions/Attached Structures

Age Size


Describe Unattached Structures

Age Size


GENERAL INFORMATION POLICY INFORMATIONNeed help with this question call 1-800-361-8734 !
Rate Territory Need help with this question call 1-800-361-8734 ! (If You Do Not Know Leave Blank - We Will Look Up )     COVERAGES COVERAGE LIMITS    
Usage               Mobile Home and Additions      
If RENTAL, is Mobile Home currently occupied by tenant?   Unattached Adjacent Structures      
Protection Class (Fire District Protection Rating -      If You Do Not Know Leave Blank - We Will Look Up ) Need help with this question call 1-800-361-8734 !     Personal Effects      
          Personal Liability      
Year Mobile Home Manufactured   YYYY   Medical Payments to Others      
How long has insured lived in the Mobile Home?     Deductible     
Prior Insurance       Territory 1 - Wind, Hurricane and Hail Excluded

 Hemphill Insurance Agency will provide Texas Windstorm Insurance Pool (TWIP) Quote.

Prior Company & Policy #          
     ***Coverage OptionsNeed help with this question call 1-800-361-8734 !
Supplemental Heating If other  Select Optional Coverage Requested    
      Owner and Landlord Liability For Rental Units Rented To Others      
Wood, Masonite or Vinyl Siding         Satellite System - Limit  $5,000      
        Additional  Premises Liability   +      
Animals on Premises Breed of Dog   Number of Secondary Residences        
Type of Animal           Number Rented to Others       
    Replacement Cost On Personal Effects RATE $0.30 Per $ 100 Of Coverage                     $ 25 Minimum Premium Applies      
Park Status # of spaces   Lien Holders - Lenders Interest  Rate $ 15            
      # 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                 
      Full Time Onsite Park Manager?       Supplemental Heating Surcharge - Add $40       
Scheduled Personal Property  Need help with this question call 1-800-361-8734 ! Delete Flood Coverage - Subtract $ 35.00                   

List Scheduled Personal Property - 

  COVERAGE LIMIT REQUESTED     Lien Holders Natural Disaster Coverage       Rate $ 5                           


    Golf Cart $100 Deductible        Rate $ 35                              

      30 Day Trip Coverage To Move Unit    $100 Deductible    Rate $ 50 S . Wide $ 100 Double Wide       

      Trip Date      

      Mobile Home Replacement Cost   Available To Units 0-10 Years Old    Rate $ 10      


      Rates Shown Above Are      For Special L.O.B 37 Only      





Totals $ RATE $2.50 Per $ 100 Of Coverage        
PROPERTIES WITH HIGHER THAN AVERAGE RISK FACTORSNeed help with this question call 1-800-361-8734 !

 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?
2. Is the home vacant, under construction/major renovation or in foreclosure?
3. Does the home have a kerosene heater or heat reclaiming device?
4. Does the home have a wood, coal or pellet burning device that is used as the primary source of heat?
5. Is there any childcare, homecare, lodging, auto repair or chemical processing conducted on the premises?
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?
(If yes, the risk may be written if the A
nimal Liability Limitation is attached. The maximum liability limit for the policy is $10,000.)

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?
2. Is there a trampoline on the premises?
3. Is there a dock, pier or boathouse on the premises?
4. Is the home without permanently installed steps at all entrances?
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.
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?
3. Has the applicant filed for bankruptcy in the past 3 years?
4. Has the applicant been delinquent in mortgage payments in the past year?
5. Has the applicant been uninsured for more than 30 days immediately prior to the requested effective date? (Not applicable to new purchases)
6. Does the home have an open foundation or is it built on stilts, posts or piers? Photos must be included.
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.
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.
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)?
10. Are there any horses, livestock or farm animals on the premises?
11. Does the premises have 5 or more acres?
12. Is there any business or farming activities conducted on the premises?
13. Does the home have 3 or more steps on any exit without a handrail? Photos must be included.
  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 




American Reliable Insurance Company Policy Forms Are Mailed , Emailed , or Faxed Along With Each Quote We Provide

Note: These Sample Policy Forms Represent Current American Reliable Insurance Company Mobile Home Policy Forms

Coverage proposals presented to you by our Agency may differ; as each insurer represented may offer modified coverage by endorsement or have filed it's own unique policy forms with the Texas Department Of Insurance. Please carefully read any carrier prepared proposal presented to you and where necessary request a copy of each insurance company policy and endorsement form presented; so that you may compare any differences in coverage offered.


 Click Here To Get Underwriting Guidelines, Territories , & Rate Tables    Need help understanding underwritng questions , rules, or rate tables call 1-800-361-8734 !