Requested Effective Date (dd/mm/yyyy):  *

d/b/a:

Mailing Street Address:  *

City:  *

State:  *

Zip Code:  *

County:

Primary Location Street Address:  *

City:  *

State:  *

Zip Code:  *

County:

Additional Location Street Address:

City:

State:

Zip Code:

County:

Additional Location Street Address:

City:

State:

Zip Code:

County:

I own more locations:  Yes   No 

Contact Name:  *

Title:

Phone Number:  *

Fax Number:

Email Address:

Web Site Address:

Total Number of Mobile Home Community Sites:

Total Number of Park Owned Rental Units:

Total Number of Tenant Owned Units:

Total Number of Tent Sites:

Total Number of Short Term (less than 3 mos.):

Total Number of Long Term (over 3 mos.) RV Sites:

What is the average percent of spaces/units unoccupied at any time (%)?

What is your average annual tenant turnover rate (%)?

What is the average monthly rent per site ($USD)?

What is the average monthly rent per Rental Unit ($USD)?

Has the Park ever been served with a Civil, Criminal or Resident Litigation?  Yes   No 

If yes, please explain:

Please provide annual sales from:

Space Rental ($USD)

Unit Rentals ($USD)

LP or Fuel ($USD)

Store/Grocery ($USD)

Laundry Facilities ($USD)

Mobile Home Sales ($USD)

Other (Please Describe):

Do you allow pets?  Yes   No 

If yes, please describe pet restrictions in your park rules:

Have you had incidents involving injury or damage caused by a tenant's pet in the past 5 years?  Yes   No 

If yes, please describe:

Are vicious breeds (such as Pitbulls, Rotweilers, Dobermans, etc.) allowed?  Yes   No 

Swimming Pools:  Yes   No 

If yes, how many?

Claims History:

Date of Claim................................Description of Loss......................Amount of Claim ($USD)

Supplemental Property Information:

Year Built.........Description of Property..................Bldg Limit ($)......Contents($)......Sq.Feet

Business Income/Year ($USD):