Tiny House/Yurt Questionnaire Tiny House/Yurt QuestionnaireΔ Applicant Information Tell us about yourself. Applicant's First NameLast NameApplicant's Date of Birth Applicant's OccupationApplicant's Marital Status- Choose -SingleMarriedPartnerDivorcedApplicant's Email AddressApplicant's Phone NumberIs there a co-applicant? Yes No Is your tiny home on wheels? Yes No Is your tiny home in poor condition? (maintenance issues) Yes No Is this tiny home on water (boat)? Yes No Is this a Tree House? Yes No Does the tiny home have liquid fuel powered space heaters? Yes NoPreviousNextCo-Applicant Information Tell us about yourself. Co-Applicant's Full Name (if applicable)Co Applicant's Date of Birth Co Applicant's OccupationCo Applicant's Marital Status- Choose -SingleMarriedPartnerDivorcedPreviousNextLocation Information Please provide your mailing and physical addresses, including any site/lot numbers. Mailing AddressAddress Line 1Address Line 2CityStateZip CodePhysical Address (location of dwelling) Address Line 1Address Line 2CityStateZip CodePreviousNextCoverage Limits Please read these questions carefully. Replacement Value of Structure (Cov A) max. $150,000Other Structures (Cov B) max. $25,000Damage of Personal Contents (Cov C) max. $25,000 Theft of Personal Contents (Theft Cov C) max. $3,000 - Select -$1,000$1,500$2,000$2,500$3,000EXCLUDEWould you like coverage for theft of the tiny house? Yes NoPersonal Liability Coverage I have a separate homeowner's policy with extended liability. I do not have a separate homeowner's policy with extended liability.Earthquake Coverage Yes NoRequested Deductible $500 $1,000 $2,500Personal Articles Floater Yes NoWould you like a quote on any other type of insurance?- Choose -AutoLifeBusinessHealthMedicareNoOtherPreviousNextAdditional Rating Information A few more questions about your dwelling. Who built your tiny home?Where did you get your trailer from?- Choose -Self MadeTrailer ManufacturerProvided by BuilderNot on WheelsWhat is the usage type of your dwelling?- Choose -Primary ResidenceSecondary ResidenceShort-Term RentalLong-Term RentalVacant (NO PERSONAL LIABILITY AVAILABLE)Construction Type- Choose -FrameMasonryMetalWhat is the purchase price of our dwelling?What year was your dwelling built?Serial/VIN of TrailerLength of Dwelling (in feet) Width of Dwelling (in feet)Total Square Footage of Dwelling (including any lofts) ***tiny home cannot exceed 500 square feet***Primary Heat Source- Choose -ElectricGasPropaneWood Stove/FireplaceNo HeatIs there a wood stove/fireplace in the dwelling? Yes NoType of Roofing- Choose -ShingleMetalWoodMembraneOtherDo you have any claims within the last 3 years? Yes No Is business conducted on the premises? Yes NoWithin the last 5 years, have you experienced bankruptcy? Yes NoIs this a container home? Yes No Is this home under construction? Yes NoEstimated Number of Moves Per YearPreviousNextMortgagee/Additional InsuredDo you need a mortgagee or landowner listed on the policy as an additional insured? Yes NoMortgagee/Additional Insured InformationAdditional Insured/Mortgagee NameAdditional Insured/Mortgage Mailing Address Interest in Policy Landowner Mortgagee OtherMortgage Loan NumberOther Previous Submit Form