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Manufactured Housing Community Owners

Insurance Questionnaire


Individual Partnership Corporation Limited Corporation Joint Venture
Mailing Address:
City: State: Zip Code:
Contact Name:
City: State: Zip Code:
Phone: Fax:
Number of Years In Business At This Location?
Name of Park
Location Address:
City: State: Zip Code:
Year Built:
1. Are You a Member of the State Mfg Housing Association? Yes No
2. Current Name of Insurance Company:
3. Current Policy #: Expiration Date:
4. Have You Had Any Losses or Incidents During the Past 5 Years? Yes No
If YES above, please explain. Include loss date, description, amount paid.
5. Has Your Insurance Been Cancelled or Non-Renewed in the Past 3 Years? Yes No
if Yes Above, please explain:
6. Is There a Manager on Premises? Yes No Full Time or Part Time
7. Total Number of Employees Estimated Annual Payroll $
8. Current Monthly Rent per Space:$  Rental Spaces:
9, Occupied-Mobile Home Spaces Rented to Others:
10.Vacant Mobile Home Spaces:
11. Occupied by Mobile Homes You Rent or Own:
12. Total Number of Rental Spaces (Mobile Homes):
13. Other Residential/Habitional Units: Describe:
14. Are Mobile Homes Skirted? Yes No
15. Are Mobile Homes Tied Down? Yes No
16. Do You Sell New Units In Your Park? Yes No # Per Year:
17. RV Spaces Rented to Others Overnight
18. RV Spaces Rented to Others Monthly:
19. Estimated Average Age of Mobile Homes in Park:
20. Is There a Minimum of 15 Foot Spacing Between Mobile Homes? Yes No
21. Do Your Employees Set Up Homes? Yes No
22. Street Construction Through Park: Paved Gravel Dirt
23. Street Lighting: Full Partial None
24. Do You Own or Operate Any Other Business at this Location? Yes No
25. Any Real Estate Development? Yes No
26. Any Vacant Land? Yes No Number of Acres
27. Are Pets Allowed in the Park? Yes No (Must provide a copy of Pet Rules)
28. Restrictions:  
29. Are Breeds Such as Dobermans, Pit Bulls, Rottweilers, Chows, or Wolf Hybrids Allowed? Yes No
30. Do You Obtain Certificates of Insurance from all Independant Contractors and Service Vendors? Yes No
31. Do You Maintain a Physical Improvements and Maintenance Log? Yes No
32. Are Any Facilities Open to the Public? Yes No
if yes, describe:
33. Are Rules and Regulations in Place and Enforced? Yes No (provide copy of your park rules)
34. Does the Park Provide Any of the Following (indicate number of facilities)

  Tennis Court Golf Course(# holes) Playground Exercise Room Computer Center Spa/Sauna Other- Describe

35. If Any of the Above is Provided, Please Describe, including type of equipment used, and What Safety Precautions Are in Place.
36. Does the Park Provide any of the Following  Swiimming Pool Diving Board/Slide Jacuzzi
37. Any Other Water Exposure (Lake, Swimming Beach, Creek etc)? Yes No
38. Name of Responding Fire Department:  
39. Nearest Responding Fire Station: Miles
40. Distance from Nearest Hydrant? Feet
41. Any Adjacent Brush, Grass, or Forest Fire Hazard? Yes No
42. Is the Park Inside or Outside the City Limits? Inside Outside
43. Please Explain any Unusual Hazards, Such as Wind, Hail, Falling Trees, Landslide, Etc.
44. Does the Park Sell or Service any Propane or Gas Yes No
45. Please Describe (# of pounds of propane or gallons of gas, receipts from these operations, # of pumps, etc)
46. Are Utilities Underground? Yes No
47. City Sewer or Septic Tank Sewer Septic
48. City Garbage or Private City Private
49. City Water or Well City Well
50. % of Single Wide Double Wide 8 ft Wide
51. Percentage of Family Adult Only Retirement Mixed
52. Park Well Maintained and Show Pride of Ownership? Yes No
53. Please describe the general condition of the park, and/or any unusual features it may have, such as licensed or unlicensed business use; autos; mobile equipment used to maintain the premises (tractors, snowplows, etc.); recreational facilities; and any other facilities provided for the use/benefit of your tenants (sponsor activities; aerobics; fitness classes; tours; shuttle service; garage sales; hobby classes; etc.).
Signature Date
  Forms by Dime Store Designs