Reliable Policy Management North Carolina Product Listing, Forms and Documentation

The following products are available. For a detailed summary of each product, please refer to the Agent Guidelines manuals for each product.

• Manufactured/Mobile Home/Modular Home Insurance - not writing new business in all counties
• Prime AD and Family Plan Accidental Death & Dismemberment (AD&D)
• Motor Club Membership

Forms and Documentation:
     The date following the product is the last update.

Aegis Security Insurance Company (Manufactured/Mobile Home/Modular Home Insurance - not writing new business in all counties)

• Aegis NC Manufactured Home Insurance:

• Underwriting for all Programs Edition 9-(8/08)

• Rates Pages:

• Multi-sectional Manufactured Home Rates – MH(F)3 Edition 4-(8/08)
• Standard Manufactured Home Rates – MH-C Edition 4-(8/08)
• Rental Manufactured Home Rates - Rental Edition 3-(8/08)

• Special Forms:

• NC Special Forms (8/08)
• NC Special Forms Package (8/08)
• Acknowledgment of No Coverage Bound
• Acknowledgment/Personal Liability Exclusion
• Affidavit of Inspection & No Existing Damage
• Agency Fact Sheet (8/08)
• Agent Appointment Form (8/08)
• Cancellation Request Form (8/08)
• Checklist for Manufactured Home Components
• General Change Form
• Manufactured Home Application
• Manufactured Home Loss Notice/Claim Form (8/08)
• Manufactured Home Quote Sheet
• No Loss Statement (8/08)
• Permission to Check Credit History Form
• Rental Unit Description Form
• Rule A Questionnaire
• Supply Order Form (8/08)
• W-9 Form

• Policy Forms for ALL Aegis Security Ins. Co. N.C. Manufactured Home Programs: (The Policy Forms are SEPARATE FOR EACH N.C. Program (MH-C/Standard, MH-F/Multi-sectional & AS-1/Rental).

•MH-F Program/Multi-sectional Program Policy Forms (6/07)

• *Mobile Homeowner Policy MH-F
• Additional Insured Endorsement
• *Communicable Disease Exclusion...Endorsement
• *Comprehensive Form Endorsement
• Mobilehome Lienholder's Single Interest Endorsement
• Mobile Home Replacement Cost Loss Settlement Endorsement
• *Mobile Home Tie Down Endorsement
• Personal Property Replacement Cost Endorsement
• *Special Provisions
• ***Windstorm or Hail Exclusion

* These forms are mandatory on any policy written in the N.C. MH-(F)/Multi-sectional Program.
*** Endorsements/premium credits not offered at this time.

• MH(C) Program/Standard Program Policy Forms (6/07)

• *Mobile Homeowner Policy MH(C)
• ***Acknowledgment of No Coverage for Windstorm or Hail Endorsement
• Additional Insured - Non Resident Endorsement
• *Communicable Disease Exclusion...Endorsement
• Mobile Home Replacement Cost Coverage Endorsement
• **Mobile Home Tenants Coverage Endorsement
• *Mobile Home Tie-Down Endorsement
• Personal Effects Replacement Cost Endorsement
• *Special Provisions Amendatory Endorsement
• ***Windstorm or Hail Exclusion Endorsement

* These forms are mandatory on any policy written in the N.C. MH(C)/Standard Program.
** This form applies only for the Tenant Policy; the Tenant Program is a sub-program in the MH(C) / Standard Program.
*** Endorsements/premium credits not offered at this time.

• AS-1/Rental Program Policy Forms (6/07)

• *Manufactured Home Policy AS-1
• Additional Insured Endorsement
• *Amendment of Policy Provisions Endorsement
• Outside Radio or Television Antenna Endorsement
• **Premises Liability - Rented to Others Endorsement
• $500 Windstorm Deductible
• $1,000 Windstorm Deductible Endorsement

*These forms are mandatory on any policy written in the N.C. AS-1/Rental Program.
** This form applies only when Premises Liability coverage is selected (added) and extra premium is charged for this coverage.

• Triangle Life Insurance Company (Prime AD):

• Prime AD - NC Agent Guidelines Edition 8-(7/08)
• Agency/Agent Licensing Forms Package (8/08)
• Cancellation Request Form (8/08)
• Claim Form for Accidental Death, Dismemberment or Loss of Sight
• Endorsement Form (8/08)
• Life of the South Agent Profile/Background Authorization & Disclosure Form (8/08)
• NC Prime AD Forms Package (8/08)
• Supply Order Form (8/08)
• W-9 Form

• American Guaranty Insurance Company (Family Plan):

• Family Plan-NC Agent Guidelines Edition 8-(7/08)
• Agency/Agent Licensing Forms Package (8/08)
• Cancellation Request Form (8/08)
• Claim Form for Accidental Death, Dismemberment or Loss of Sight (8/08)
• Endorsement Form (8/08)
• Family Plan Forms (8/08)
• Life of the South Agent Profile/Background Authorization & Disclosure Form (8/08)     
• Supply Order Form (8/08)

• NC Roadmaster (Motor Club) - underwritten by Nation Safe Drivers:

• Roadmaster Motor Club Plan Edition 2-(8/08)
• Agency/Agent Licensing Forms Package (8/08)
• Agent Application
• Agency Fact Sheet (8/08)
• Cancellation Request Form (8/08)
• Claim Form
• Member Address Change Form (8/08)
• NC Roadmaster Forms (8/08)
• RPM Roadmaster Agreement
• Supply Order Form
• Transmittal Form
• W-9 Form

Note: Adobe Reader version 6.0 or later is required to view and print  these forms.