Mobile Home Insurance Application

Agency Name: King Insurance Systems, Inc.   First Named Insured:   Address:   City: State: Zip:   County: Phone No.:                 AGE: D.O.B.   Second Named Insured:                 AGE: D.O.B.   Add'l Insured:   Address:   City: State: Zip:   Address:   City: State: Zip:   County: Phone No.:   Name:   Address:   City: State: Zip:   County: Phone No.:   Loan #:   1. Name:   Address:   City: State: Zip:   County: Phone No.:   INELIGIBLE RISK YES NO 1. Is Mobile Home homemade, custom-built or substantially altered? 2. Is Mobile Home under construction or not fully installed? 3. Is business conducted on insured premises? 4. Was applicant previously uninsured for 30 or more days? 5. Is there an un-fenced swimming pool on insured premises? 6. Has mobile home been reconstructed due to a total flood loss? 7. Has applicant sustained any loss in the last 3 years? If yes, submit. 8. Is Mobile Home unoccupied or vacant for more than 30 days? 9. Does applicant own or board a Doberman, Rottweiller, Pit Bull or gurad dog or with a history of biting or board horses? 10. Is Rental/Commercial Mobile Home used as a motel or unoccupied for period of less than 6 months?

From: To: 12 Month Term For Coverage to begin as requested, application and premium payment must be mailed within 72 hours of the effective date; otherwise coverage is bound 12:01AM the day received by the Company.   Prior Carrier:   Is M.H. In-Park? ; If No, is land owned?   Park Name:   Total Spaces: Space #: Protection Class:   Responding Fire Dept.:   Distance to fire hydrant:(ft); fire station:(mi) Primary Residence Rental Tenant Seasonal   If Rental, Name of Tenant(s):   Manufacturer:   Serial Number:   Width:(ft) Length:(ft) YEAR BUILT:   Does Mobile Home have Bracing? Skirted?   Heat Source:   Auxilliary heating or a fireplace?   Type of Structures: Porch Deck Other   Attached Stuctures Description: Attached Garage   Use: Value $:   Width:(ft) Length:(ft) YEAR BUILT: Built by a Professional Contractor?   Auxilliary heating or a fireplace?   Unattached Structures Description: Shed   Use: Value $:   Width:(ft) Length:(ft) YEAR BUILT: Built by a Professional Contractor?   Auxilliary heating or a fireplace?   UNDERWRITING YES NO 1. Is risk located in an area subject to excessive exposure to any peril? If yes, submit description. 2. Is M.H, in an area subject to flooding or located less than 1000 ft. from any river, ocean, bay, or flood prone area or on a site which has flooded in the last 10 years? If yes, exclude flood. 3. Is Earthquake Coverage Being Accepted?

In-Park Territory:   Park Type: Replacement Cost (To Policy Limit Only) M.H. & Attached Structure Value: Basic Annual Premium: Guaranteed Replacement Cost Mobile Home Model "Tamarack" Construction Grade "Standard" Replacement Cost = $40 per SF Mobile Home - 1440SF @ $40/SF: Additional M.H. Coverage: Attached Structure Value:   Total Value: Basic Annual Premium: Earthquake Coverage Zone "92692", Rating Band "1" Base Rate with 15% Coverage "A" Deductible Rate:   Premium:

Natural Disaster Protection Secured Interest Protection Add'l Residence Premises Liability Golf Cart Coverage Woodburning Stove Workers' Comp. - Residence Employees Loss Assessment Add'l Limit for Radio & TV Antenna Add'l Unattached Structures Add'l Personal Effects Add'l Personal Liability Add'l Medical to $1000 Limit Scheduled Personal Property Sewer Backup Lien Free Credit Flood - $250 Deductible Other Windstorm & Hail Exclusion Animal Liability Exclusion $100 Deductible $500 Deductible Protective Device Credit Basic Premium Optional Premium Credits & Debits Earthquake Premium Policy Fee (Fully Earned) Broker's Fee TOTAL

Applicants Acknowledge that by signing this application they have read and accepted the attached terms and conditions.

1st Applicant's Signature/Date:

2nd Applicant's Signature/Date:

Producer's Signature/Date:

31878 Camino Capistrano, Suite 270, San Juan Capistrano, CA 92675