Personal Information |
| * Name: |
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| Business Name: |
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| * Address: |
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| City: |
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| State: |
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| Zip: |
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| * Home Phone: |
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| Business Phone: |
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| Fax: |
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| * Email: |
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Building & Property Information |
| * Property Street |
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| * Property City |
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| * Property State |
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| * Property Zip |
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| What is the occupancy type? |
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| What is the building type? |
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| What year was it built? |
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What is the flood map
zone number? |
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| What is the community flood number? |
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| How many Bedrooms? |
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| How many bathrooms? |
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| How many fireplaces? |
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| What date was it purchased? |
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Does the residence
have a basement? |
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What is the total square
footage of the building? |
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How many units
are in the building? |
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| What is the garage description? |
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| How many stories is it? |
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What is the
construction type? |
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What is the
foundation type? |
Foundation Type
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What is the nature
of sub-soil? |
Nature of Sub-Soil
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| What is the topography? |
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| What type roof covering? |
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| Is the roof updated? |
Yes
No |
| If yes, what year? |
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Is there any erosion
in the area? |
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Is there any
below ground parking? |
Yes
No |
| Is there any soft first story or tuck under parking? |
Yes
No |
What is the distance of fire protection?
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Is the business
in a brush area? |
Yes
No |
| If yes, has the brush been cleared by 250 feet
from all around the building? |
Yes
No |
Are there smoke
detectors at this location? |
Yes
No |
Are there fire
extinguishers? |
Yes
No |
| Are there circuit breakers? |
Yes
No |
| Is the electrical updated? |
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How old is the
heating/ air conditioning? |
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| What is the energy source? |
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Has the plumbing
been updated? |
Yes
No |
If yes, what year was
the plumbing updated? |
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| Is the plumbing copper? |
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| Does the building have interior automatic fire
sprinklers? |
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| Is there a fire alarm? |
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Has the building been
retrofitted or bolted? |
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| |
Claims Information |
| Where there any losses or claims
in the last 5 years? |
Yes
No |
If yes, what is the date, amount
paid
and description
of each loss or claim? |
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| |
Coverage Information |
| What is the current insurance
company? |
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How much
are you paying now? |
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| What is the building coverage
requested? |
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| What is the other structures coverage
requested? |
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| What is the contents property
coverage requested? |
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| What is the loss of use coverage
requested? |
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| Are there any questions, comments
or additional coverage required? |
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