ACORD 72 (2009/10)

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 10/30/2009.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 72 (2009/10)
Mobile Home Supplement
The titile of the form. ACORD 72, Mobile Home Supplement, is used with ACORD 89,
Residential Section or ACORD 80, Homeowners Application, to provide information about
mobile homes and the type of tie-down protection provided for the mobile home. Consult
your company as to when this supplement is required.
IDENTIFICATION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION
Loc #
Enter number: The producer assigned number of the location. As used here, the location
number of the risk's location as it appears on ACORD 88, Personal Insurance Application,
Applicant Information Section or ACORD 80, Homeowners Application.
IDENTIFICATION
Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION
Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION
Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
MOBILE HOME RATING /
UNDERWRITING
Property Address - Street
Enter text: The first address line of the physical location. As used here, Property Address
should include: Street number, if any; Pre-direction, if any (example: 150 N Central Ave);
Street name, if any; Street type (e.g.: st., rd, ave.) ; Post-direction, if any (e.g.: 150 Central
Ave N); City; County; State; ZIP code
If the address does not have a street number and name, provide sufficient information and
directions so that the property can be physically located. Provide legal description if
required by the mortgage holder.
MOBILE HOME RATING /
UNDERWRITING
Property Address - City
Enter text: The city of the physical location.
MOBILE HOME RATING /
UNDERWRITING
Property Address - County
Enter text: The county of the location.
ACORD 72 (2009/10)
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Section Name
Field Name
Field and/or Section Description
MOBILE HOME RATING /
UNDERWRITING
Property Address - State
Enter code: The state or province of the physical location.
MOBILE HOME RATING /
UNDERWRITING
Property Address - Zip+4
Enter code: The postal code of the physical location.
MOBILE HOME
RATING/UNDERWRITING
New (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if the mobile home was
purchased new.
MOBILE HOME
RATING/UNDERWRITING
Year
Enter year: The model year of the mobile home.
MOBILE HOME
RATING/UNDERWRITING
Make
Enter text: The name of the manufacturer of the mobile home.
MOBILE HOME
RATING/UNDERWRITING
Model
Enter text: The manufacturer's model name for the mobile home.
MOBILE HOME
RATING/UNDERWRITING
ID Number
Enter identifier: The serial number for this mobile home.
MOBILE HOME
RATING/UNDERWRITING
Length
Enter number: The length of the mobile home expressed in feet.
MOBILE HOME
RATING/UNDERWRITING
Width
Enter number: The width of the mobile home expressed in feet.
MOBILE HOME
RATING/UNDERWRITING
Doublewide
Enter Y for a Yes response. Input N for No response. Indicates if the mobile home is a
doublewide construction.
MOBILE HOME
RATING/UNDERWRITING
Skirted
Enter Y for a Yes response. Input N for No response. Indicates if the mobile home is
skirted.
MOBILE HOME
RATING/UNDERWRITING
# of Bedrooms
Enter number: The number of bedrooms in the mobile home.
MOBILE HOME
RATING/UNDERWRITING
Tie Down - None (checkbox)
Check the box (if applicable): Indicates the mobile home has no tie downs.
MOBILE HOME
RATING/UNDERWRITING
Full (checkbox)
Check the box (if applicable): Indicates the mobile home tie downs are full.
MOBILE HOME
RATING/UNDERWRITING
Chassis Only (checkbox)
Check the box (if applicable): Indicates the mobile home tie downs are chassis only.
MOBILE HOME
RATING/UNDERWRITING
Overtop Only (checkbox).
Check the box (if applicable): Indicates the mobile home tie downs are overtop only.
MOBILE HOME
RATING/UNDERWRITING
Permanent Connection - Electricity
(checkbox)
Check the box (if applicable): Indicates the mobile home has a permanent connection to
electricity.
MOBILE HOME
RATING/UNDERWRITING
Water (checkbox)
Check the box (if applicable): Indicates the mobile home has a permanent connection to
water.
ACORD 72 (2009/10)
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Section Name
Field Name
Field and/or Section Description
MOBILE HOME
RATING/UNDERWRITING
Sewer (checkbox)
Check the box (if applicable): Indicates the mobile home has a permanent connection to
the sewer.
MOBILE HOME
RATING/UNDERWRITING
Cooking Location - End
(checkbox)
Check the box (if applicable): Indicates the mobile home has a cooking location at the end
of the residence.
MOBILE HOME
RATING/UNDERWRITING
Middle (checkbox)
Check the box (if applicable): Indicates the mobile home has a cooking location in the
middle of the residence.
MOBILE HOME
RATING/UNDERWRITING
None (checkbox)
Check the box (if applicable): Indicates the mobile home has no cooking location.
MOBILE HOME
RATING/UNDERWRITING
Mobile Home Foundation -
Continuous Masonry
Check the box (if applicable): Indicates the foundation is continuous masonry.
MOBILE HOME
RATING/UNDERWRITING
Mobile Home Foundation - Post &
Pier
Check the box (if applicable): Indicates the foundation is post and pier.
MOBILE HOME
RATING/UNDERWRITING
Mobile Home Foundation - Other
Check the box (if applicable): Indicates the foundation is other than those listed.
MOBILE HOME
RATING/UNDERWRITING
Mobile Home Foundation - Other
Description
Enter text: The foundation of the mobile home.
MOBILE HOME
RATING/UNDERWRITING
Mobile Home Park Name
Enter text: The name of the mobile home park.
MOBILE HOME
RATING/UNDERWRITING
Date Park Established
Enter date: The date the mobile home park was established.
MOBILE HOME
RATING/UNDERWRITING
Number of Permanent Spaces in
Park
Enter number: The number of permanent spaces in the mobile home park.
MOBILE HOME
RATING/UNDERWRITING
Consecutive Months Occupied
Each Year
Enter number: The number of consecutive months the mobile home is occupied each
year.
GENERAL INFORMATION - 1. Does mobile home park have a
MOBILE HOME
resident manager?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the
question, Does the mobile home park have a resident manager?.
GENERAL INFORMATION -
MOBILE HOME
Manager's Name
Enter text: The full name of the manager of the mobile home park.
GENERAL INFORMATION -
MOBILE HOME
Phone Number
Enter number: The phone number of the manager of the mobile home park.
GENERAL INFORMATION - 2. Does mobile home park have
MOBILE HOME
limited access?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the
question, Does the mobile home park have limited access?.
GENERAL INFORMATION -
MOBILE HOME
Description
Enter text: An explanation of a response to a general information or underwriting question.
Normally, Yes responses require an explanation.
GENERAL INFORMATION - 3. Does mobile home park have
MOBILE HOME
subdivisions?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the
question, Does the mobile home park have subdivisions?.
ACORD 72 (2009/10)
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION -
MOBILE HOME
Description
Enter text: An explanation of a response to a general information or underwriting question.
Normally, Yes responses require an explanation.
GENERAL INFORMATION - 4. Are roads unpaved in the mobile
MOBILE HOME
home park?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the
question, Are any roads unpaved in the mobile home park?.
GENERAL INFORMATION -
MOBILE HOME
Description
Enter text: An explanation of a response to a general information or underwriting question.
Normally, Yes responses require an explanation.
CERTIFICATION OF
MOBILE HOME TIE DOWNS 1. Is mobile home tied down?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is mobile home tied down? If yes, answer questions 2 through 13)..
CERTIFICATION OF
MOBILE HOME TIE DOWNS tie down strapping?
2. Is mobile home equipped with
factory installed under the skin
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is mobile home equipped with factory installed under the skin tie down
strapping?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS 1 1/4 Steel Strap
3. Type of Straps or Cables Used:
Check the box (if applicable): Indicates the type of straps used to tie down the mobile
home are 1 1/4 steel strap.
CERTIFICATION OF
MOBILE HOME TIE DOWNS 1 1/2 Steel Strap
3. Type of Straps or Cables Used:
Check the box (if applicable): Indicates the type of straps used to tie down the mobile
home are 1 1/2 steel strap.
CERTIFICATION OF
MOBILE HOME TIE DOWNS 1/4 Steel Cable
3. Type of Straps or Cables Used:
Check the box (if applicable): Indicates the type of cable used to tie down the mobile
home are 1/4 steel cable.
CERTIFICATION OF
MOBILE HOME TIE DOWNS 1/2 Steel Cable
3. Type of Straps or Cables Used:
Check the box (if applicable): Indicates the type of cable used to tie down the mobile
home are 1/2 steel cable.
CERTIFICATION OF
MOBILE HOME TIE DOWNS Other
3. Type of Straps or Cables Used:
Check the box (if applicable): Indicates the type of straps or cable used to tie down the
mobile home is other than those listed.
CERTIFICATION OF
MOBILE HOME TIE DOWNS Other, describe
3. Type of Straps or Cables Used:
Enter text: The description of the type of straps or cable used to tie down the mobile
home.
CERTIFICATION OF
MOBILE HOME TIE DOWNS downs galvanized?
4. Is all strapping used in tie
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is all strapping used in tie down galvanized?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS downs without perforations?
5. Is all strapping used in tie
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is all strapping used in tie downs without perforations?.
ACORD 72 (2009/10)
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Section Name
Field Name
Field and/or Section Description
CERTIFICATION OF
MOBILE HOME TIE DOWNS firmly clamped and secure?
6. If cable used, are loose ends
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, If cable used, are loose ends firmly clamped and secure?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS visible?
7. Are over the roof tie downs
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are over the roof tie downs visible?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS cable to prevent sharp bends?
7 a. If over the roof tie down are
visible, are corner blocks of wood
or metal used under strapping
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, If over the roof tie down are visible, are corner blocks of wood or metal used
under strapping cable to prevent sharp bends?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS Downs?: Dead Men
8. Type of Anchors used for Tie
Check the box (if applicable): Indicates the type of anchors used for the tie downs are
dead men.
CERTIFICATION OF
MOBILE HOME TIE DOWNS Downs?: Screw Auger
8. Type of Anchors used for Tie
Check the box (if applicable): Indicates the type of anchors used for the tie downs are
screw auger.
CERTIFICATION OF
MOBILE HOME TIE DOWNS Downs?: Other Tie Down Anchors
8. Type of Anchors used for Tie
Check the box (if applicable): Indicates the type of anchors used for the tie downs are
other than those listed.
CERTIFICATION OF
MOBILE HOME TIE DOWNS Downs?: Explain
8. Type of Anchors used for Tie
Enter text: The description of the screw auger or other tie down anchors.
CERTIFICATION OF
MOBILE HOME TIE DOWNS downs?
9. Are turnbuckles used in tie
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are turnbuckles used in tie downs?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS downs, are they forged steel?
9 a. If turnbuckles are used in tie
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, If turnbuckles are used, are they forged steel?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS jaws properly secured?
9 b. Are turnbuckles ending with
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are turnbuckles ending with jaws properly secured?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS hook?
9 c. Do turnbuckles end with open
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Do turnbuckles end with open hook?.
ACORD 72 (2009/10)
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Section Name
Field Name
Field and/or Section Description
CERTIFICATION OF
MOBILE HOME TIE DOWNS wire?
9 d. If turnbuckles end with open
hook, are they closed with twine or
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, If turnbuckles end with open hook, are they closed with twine or wire?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS added rooms, etc) tied down?
10. Are there any additions to
mobile home (including carport,
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are there any additions to mobile home (including carport, added rooms,
etc)?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS home tied down?
10 a. Are all additions to mobile
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are all additions to mobile home (including carport, added rooms, etc.) tied
down?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS blocked?
11. Is mobile home properly
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is mobile home properly blocked?.
CERTIFICATION OF
MOBILE HOME TIE DOWNS blocked? If NO, explain
11. Is mobile home properly
Enter text: An explanation of a response to a general information or underwriting question.
Normally, Yes responses require an explanation. As used here, explain if the mobile
home is not properly blocked.
CERTIFICATION OF
MOBILE HOME TIE DOWNS roof?
12. How many properly secured
straps or cables are there over the
Enter number: The number of properly secured straps or cables that are over the roof.
CERTIFICATION OF
MOBILE HOME TIE DOWNS there? Right:
13. Facing either end of the
mobile home, how many properly
secured frame tie downs are
Enter number: The number of properly secured frame tie downs on the right side when
you are facing either end of the mobile home.
CERTIFICATION OF
MOBILE HOME TIE DOWNS there? Left
13. Facing either end of the
mobile home, how many properly
secured frame tie downs are
Enter number: The number of properly secured frame tie downs on the left side when you
are facing either end of the mobile home.
IDENTIFICATION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION
Loc #
Enter number: The producer assigned number of the location.
CERTIFICATION OF
MOBILE HOME TIE DOWNS Explanation of Items Not
(Continued)
Adequately Described Above
Enter text: An explanation of a response to a general information or underwriting question.
Normally, Yes responses require an explanation. As used here, explain any items not
adequately described above
CERTIFICATION OF
MOBILE HOME TIE DOWNS
(Continued)
Signature of Owner / Applicant
Sign here: Accommodates the signature of the applicant or named insured.
ACORD 72 (2009/10)
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Section Name
Field Name
Field and/or Section Description
CERTIFICATION OF
MOBILE HOME TIE DOWNS
(Continued)
Date
Enter date: The date the form was signed by the named insured.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 72 (2009/10)
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