Mobile/Manufactured Home Non-Renewal Form Owner and Property InformationName of Owner:(Required) First Last Policy Number being Non-Renewed:(Required) Any Other Owners? (Spouse or Other):(Required)Select OneYesNoOther Named Insureds:(Required) Applicant Email Address:(Required) Applicant Phone Number:(Required)Is there a Trust?:(Required)Select OneYesNoName of the Trust:(Required) Address of Home to be Insured:(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address:(Required) Same as Address of Home to be Insured Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Damages and ClaimsANY Claims in the Last 5 years?:(Required)Select OneYesNoDid you File a Claim?:(Required)Select OneYesNoIs the Claim Open or Closed?:(Required)Select OneOpenClosedDid you Experience Flood Damage?:(Required)Select OneYesNoHeight of Water (In Feet or Inches):(Required) Is all Flood Damage Repaired?:(Required)Select OneYesNoIs There Unrepaired Damage to the Property?:(Required)Select OneYesNoWhat Items were Damaged?:(Required) Add RemoveWhat Items are Unrepaired?:(Required) Add RemoveDid you Hire an Attorney for the Claim?:(Required)Select OneYesNoDid you Hire a Public Adjuster?:(Required)Select OneYesNoAmount Paid by Insurance Company for Claim:(Required)Upgrades or ReplacementsWere any Attached Structures updated, such as Converting a screen room to Vinyl or Glass Windows? (Weather Tight Room, Enclosed Carport, or any other Custom Updates):(Required)Select OneYesNoPlease Specify the Updated Structures:(Required) Any Other Updates or Upgrades:(Required)Select OneYesNoPlease Specify the Updates or Upgrades:(Required) Has your Roof ever been Replaced:(Required)Select OneYesNoWhat year was your roof fully REPLACED, not just repaired?:(Required) What is the Material of the Roof?:(Required)Select OneMetalShingleMembrane/Rolled RoofingDo you have an Attached Shed? (Under Carport, etc.):(Required)Select OneYesNoDo you have a Detached Shed (In the Back or Side Yard):(Required)Select OneYesNoDo you have a Carport?:(Required)Select OneYesNoDo you have a Garage?:(Required)Select OneYesNoNumber of Weather Tight Rooms (Glass or Vinyl Windows):(Required)Select OneNo Weather Tight Rooms12345678Number of Screen Rooms (If Any):(Required)Select OneNo Screen Rooms12345678Is there Polybutylene or "Gray" Pipes in any of your Plumbing Lines:(Required)Select OneYesNo Click here for a Polybutylene Example and Related InformationHas the Electric Panel ever been Replaced?:(Required)Select OneYesNoYear of Electric Panel Replacement:(Required) Rental and Other InformationIs the Home ever Occupied by Anyone other than you (Such as a Tenant or Short-Term Rental like AirBnB or VRBO):(Required)Select OneYesNoAbout how many Times a year is the Property Rented to Others:(Required)Shortest Rental Period for Property:(Required) How Many Months do you Occupy the Home Each Year?:(Required)Select One0-3 Months4-8 Months9 or more MonthsDo you have any Animals?:(Required)Select OneYesNoWhat kind of Animal?:(Required)Select OneDogCatOtherNumber of Dogs:(Required)Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Do you have any Other Animals?:(Required)Select OneYesNoWhat kind of Animal?:(Required)Select OneCatOtherNumber of Cats:(Required)What Other Animal(s) (Please Specify):(Required) Add RemoveNumber of Cats:(Required)Do you have any Other Animals?:(Required)Select OneYesNoWhat kind of Animal?:(Required)Select OneDogOtherNumber of Dogs:(Required)Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) What Other Animal(s) (Please Specify):(Required) Add RemoveWhat Other Animal(s) (Please Specify):(Required) Add RemoveDo you have any Other Animals?:(Required)Select OneYesNoWhat kind of Animal?:(Required)Select OneDogCatNumber of Dogs:(Required)Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Dog Breed:(Required)Select OneAkitaChow ChowDoberman PinscherGerman ShephardPresa CanarioRottweilerStaffordshire Terrier (Pit Bull)Wolf Dog HybridsOtherSpecify Other:(Required) Number of Cats:(Required)Do you have a Mortgage?:Select OneYesNoMortgage or Bank Name:(Required) Loan Number:(Required) Address of Lender:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have a Golf Cart?:(Required)Select OneYesNoIs it Street Legal With a License Tag:(Required)Select OneYesNoYear:(Required) Make:(Required) Model:(Required) Value:(Required)CAPTCHA
