ACORD 85 InstructionsACORD 85 - Mobile Home Application The underwriting process for any personal lines policy begins with the submission of a completed application. The following will provide assistance in completing ACORD 85, Mobile Home Application.
Date Month/day/year (MM/DD/YYYY) on which the form is completed.
Producer's telephone
number. (Include area code and extension if applicable) Fax No. Producer's fax
number. (Include area code) Agency Producer's name
and address. Code Identification
code assigned to the agency or brokerage firm by the insurance company receiving
this form. Subcode If the agency
or brokerage uses a sub-code identification system with the company, enter the
appropriate code. Agency Customer ID Customer's identification
number assigned by the agency or brokerage. Applicant's Name and Mailing Address Full name of the applicant as it should appear on the policy. The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first and any additional insureds identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith). Provide the physical address, not a P.O. Box, at which the first named insured is to receive all mail.
NAIC Code The identification
code assigned to the company by the NAIC. Facility Code The identification
code used by assigned risk plans, FAIR plans and other associations (only applicable
in a few states). When using this field, also enter the name of the facility
in the CO/PLAN field. Policy # The number assigned
by the insurance company for the policy. In general, policy numbers will not
appear on new business applications since they are not known at that point in
time. Years at this Res Indicate the
number of years applicant resided in current residence. CO/Plan Name of the insurance
company (or residual market plan) that will receive the application. Do not
use group names, use the actual name of the company within the group in which
you wish to have the policy issued. Also, if applicable, indicate the type of
plan or policy program (example: Preferred) that you wish to use when issuing
the policy. Use the specific plan name that is unique to that company. Home Phone # Home telephone
number at which the applicant may be reached. Include area code. Effective Date Date (MM/DD/YYYY)
on which the terms and conditions of the policy will commence. Expiration Date Date (MM/DD/YYYY)
on which the terms and conditions of the policy will terminate unless renewed. Business Phone # Business telephone
number at which the applicant may be reached. Include area code and extension,
if applicable. APPLICANT INFORMATION Previous Address Enter previous physical address of the first named insured if the applicant has been at the current address for less than three years. Also indicate the number of years at the previous address.
Enter the physical
address of the property to be insured only if it is different from the mailing
address listed above. Applicant's/Co-Applicant's Occupation Briefly describe
the occupation for the applicant(s) named in the identification section. State
the nature of the business if self employed. Applicant's/Co-Applicant's Employer Name and Address Name and address
of the organization that employs the applicant(s) named in the identification
section. Yrs in Curr. Occ. Number of years
in current occupation or business. Yrs w/Curr. Empl. Number of years
with the present employer. If less than 3 years, provide the number of years
in career field or industry in the Remarks section. Yrs w/Prior Empl. Number of years
with the prior employer. Mar Stat Marital status of each named applicant. Codes:
Date of Birth Birth date of
each named applicant (MM/DD/YYYY). (E.g., March 7, 1944 should be 03/07/1944.) Social Security # Social security
number for each named applicant. How long have you known the applicant? Indicate how long
the agent has known the applicant. Date agent last inspected property: Indicate the
date when the property was last inspected by agent. ADDITIONAL INTEREST INT# Provide the interest number or rank (1st, 2nd)
Identify whether
the additional interest is the mortgage holder (i.e., bank in which the mortgage
is held), or other interest Name and Address Provide the address
of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) for
each entity having an interest in the dwelling(s) to be insured. Loan Number Provide the loan
number. COVERAGE'S/LIMITS OF LIABILITY List the anticipated dollar limit amounts for each applicable coverage.
Enter the deductible
amount and the type (Flat, Percentage,) The deductibles may vary from one amount
for all perils to different deductibles for various coverages.. Endorsements Enter the name
of each applicable endorsement, and the applicable limit of coverage, if any. Premium Enter the estimated
total premium calculated by the insurance agency, as well as the applicant's
deposit and balance, if any owed. Payment Plan Indicate whether the agency or the company (direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan to be used for payment.
Year The model year for the mobile home, not necessarily the year the unit was manufactured.
The name of the
manufacturer. Model The name of the
model. ID Number The unique identification
number for this mobile home. Length/Width Mobile home's
exterior length and width, expressed in feet. Purchase Date/Price Year the applicant
acquired the dwelling and the purchase price. The year should be expressed in
YYYY format. New/Used Check the box
to indicate if the mobile home was purchased new by the applicant, or if it
was purchased from a previous owner. Cooking Location Check the appropriate
box to show the location of the cooking equipment within the mobile home. Tie Down Check the appropriate
box to indicate the type of tie down, if any, used to secure the mobile home
from wind damage. Terr Code Location of the
mobile home based on individual state bureau or company manual pages. Fire Prem Group The applicable
premium group based upon the mobile home's location, construction and fire protection
code. Some companies require this data; others generate it. EC Prem Group Extended coverage,
broad form and special form premium group number determined from the territory. Pers Liab Terr Code Provide the territory
code determined by the dwelling's location if the company's rate structure requires
separate rating information for personal liability. Protect Class Four character
fire protection class found in individual state manuals. Distance to Hydrant Distance (in ft.) from the nearest hydrant that supports the protection class used.
Distance to Fire Station Distance in miles
from the nearest fire station that supports the protection class used. Fire District/Code Number Fire district
name and corresponding code number which can be found in the individual state
manual pages. Protection Device Type For alarms
to qualify for credit, a copy of the manufacturer's specification sheet must
be submitted with the application. Heat Type Type of heating device for the residence. If the residence has no heat, check the box.
Occupancy Indicate by whom
the mobile home is currently occupied: owner, tenant, no occupants, or the mobile
home is vacant. Use Indicate if the
mobile home is the applicant's primary or secondary residence, or if the use
is seasonal, or rented to others. Housekeeping Condition An evaluation
of the interior upkeep of the mobile home. Exterior Construction Check the appropriate
box. Foundation Construction Check the box
that most closely describes the type of foundation. Utilities Check the appropriate
boxes to indicate which utilities are permanently connected to the structure. Wiring Check the appropriate
box to indicate copper or aluminum wiring, and show the date the wiring was
last inspected. OTHER STRUCTURES Describe any
other structure(s) to be included in Coverage B - Other Structures. LOCATION INFORMATION Mobile Home Park Name If the mobile
home is located in a mobile home park, list park name. Date park established If the mobile home is located in a mobile home park, indicate date park established.
If the mobile
home is located in a mobile home park, indicate the number of permanent spaces
in the park. Questions 1-3 If the mobile home is located in a mobile home park, give Yes or No answers to the questions relating to park management and access to the park.
Question
5 If the mobile home is not located in a mobile home park, give Yes
or No answers to the question relating to visibility from the road. GENERAL INFORMATION QUESTIONS Use the remarks
section to provide additional information for any questions answered with a
"Yes" response. 1. Any business conducted on premises? Describe the business
as well as where the business is conducted on the premises. 2. Any residence employees? Describe the number
and type of full and part time employees. 3. Any flooding, brush hazard, fire hazard, landslide, etc. Use the Remarks
section to describe the type of hazard and the distance between the residence
and the hazard. Some companies may require a photograph. 4. Any other residence owned, occupied or rented? Use the Remarks
section to detail the occupancy or use of the other residence. If no liability
coverage is requested for this residence, detail where the coverage is provided
if liability coverage is to be included in the policy for any property. 5. Any other insurance with this company? Indicate whether
other insurance is currently written for this applicant by the company. If a
submission was mailed to another department recently, note it in the Remarks
section along with any policy numbers available. 6. Has insurance been transferred within the agency? Indicate why
the insurance has been moved from the last company. 7. Any coverage declined, cancelled or non-renewed? Explain the circumstances
surrounding the situation. This question cannot be asked in certain states. 8. Has applicant had a foreclosure, repossession or bankruptcy during the past five years? Use the Remarks
section to provide information regarding any real estate foreclosure, personal
property repossession, or bankruptcy filing during the specified time period. 9. Are there any animals or exotic pets kept on the premises? Use the remarks
section to give the age, breed, or other information about livestock or pets
that may be vicious or dangerous to human beings. Also give any history of biting
or causing injury to others. 10. Is property located within two miles of tidal water? Use the Remarks
section to describe the coastal hazard, if applicable. 11. Is property situated on more than five acres? Use the Remarks
section to indicate if any part of the property is farmed, or used to grow crops
or animals for sale, or used for any other non-residential purpose. 12. Does applicant own any recreational vehicles (snowmobiles, dune buggys, ATVs, mini-bikes, etc.)? Use the Remarks
section to describe the recreational vehicle. Include the year, type, make,
model, and any other information necessary to provide a complete description. 13. During the last five years (ten in RI), has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson, or any other arson-related crime in connection with this or any other property? (In Rhode Island,
failure to disclose the existence of an arson conviction is a misdemeanor punishable
by a sentence of up to one year of imprisonment.) Rhode Island law requires
that all applicants for property insurance must answer this question. 14. Any uncorrected fire or building code violations? Describe any violations
of applicable codes that have not been corrected. 15. Is mobile home for sale? Provide the length
of time the mobile home has been for sale, and the expected sale date, if known. 16. Is property within 300 feet of a commercial or non-residential property? Describe the
occupancy of any commercial or non-residential property. 17. Is there a trampoline on the premises? Describe the device. 18. Any lead paint hazard? Describe the
location and the extent of the hazard. 19.If a fuel oil tank is on the premises, has other insurance been obtained for the tank? Give the First
Party to the insurance and the applicable limit, and the Third Party and the
applicable limit. 20. Is home doublewide construction? Indicate if the
mobile home is doublewide construction. LOSS HISTORY This section shows
the losses this applicant has had in the past. List losses for the last three
years unless the company requires a different period of time. PRIOR COVERAGE Prior Carrier Provide the prior insurance company's name.
Number List the
complete policy number including prefix and suffix. Expiration Date Provide the expiration
date of the prior insurance policy. REMARKS Use the remarks section to provide additional information for any questions answered with a "Yes" response.
Check the appropriate
box(es) BINDER/SIGNATURE This section is to be used by producers with the permission of the company underwriter or when the producer has binding authority for this line of business.
Month/day/year
(MM/DD/YYYY) on which the insurance applied for is bound. This insurance is
subject to the terms, conditions, and limitations of the company. Expiration Date Month/day/year
(MM/DD/YYYY) on which the binder terminates. Time Time the provisions
of the binder become effective. 12:01/ Noon Indicate the time
on which the binder terminates. Notice of Information Practices Check this box
if a copy of the Notice of Information Practices has been given to the applicant. Applicant's Signature The applicant
should read and understand the Fair Credit Reporting Act, the Privacy Act (where
applicable), the Applicant's Statement, and any other disclosure information
on the form before personally signing the application. Date Date the form
was signed. Producer's Signature The producer should
sign the application. This is required in most states. National Producer Number The National
Producer Number assigned by the NAIC should be shown. Sign up for Free Access to all ACORD forms. Return to Simply Easier ACORD Forms home page from ACORD 24 Instructions page.
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