Edit Form - Drag N' Drop FormBuilder

General Info

Did you get Interior photos? (All building must have interior photos unless it's residential with no access) *

Yes
No
Residential with no access

gl1- Need to correct address

Yes
No correction needed

gl2- How was the corrected address obtained

Insured
Agent
Internet search
Office assistance
Other

gl3- Other: *

gl4- Number and street: *

gl5- City, State zip code *

gl6- Were you able to obtain all the rating basis and special notes *

Yes
No

gl8- Person interviewed (first & last name)TYPE "NONE" if no interview *

gl9- Position and/or title. *

Owner
Bookkeeper
Manager
Assistant Manager
Tenant
Other
Family member

gl11- Other title *

gl12- Date of interview *

Month
Day
Year

Occupancy

occ13-Select what best fits the property *

occ16- Types of building(s) on property *

Common buildings on property
Mobile Homes owned by the insured
Single Family Dwelling
No Buildings

occ17- Swimming pool *

Yes
None

occ18- Select all that apply *

None
Restaurant
Convenience Store
Nightclub
Daycare
Playground
Laundromat/Dry cleaners
Apartment
Hotel/Motel

occ19- Select all that apply *

None
Cooking
Daycare
Playground

occ20- Select all that apply: *

None
Cooking

occ21- Select all that apply *

None
Cooking
Bar/Nightclub

occ22- Select all that apply *

None
Cooking
Bar/Nightclub
Swimming Pool

occ24- Insured's the owner or tenant *

Building Owner Only
Building Owner and Occupies the Building
Building Owner and occupies building with tenants
Tenant
POA/HOA

occ25- Does Building owner require COI (certificate of insurance) from each Subcontractor and/or tenant doing business on the property? *

Requires Certificate of Insurance
Does not require COI

occ26- Building Occupied *

Full Occupancy
Partial occupancy/vacant
Unoccupied/Vacant

occ27-Number of owners? (number only) *

occ27A What is the percent of occupancy *

occ28- Approx, what % does the building owner occupy? (number only) *

occ29- Tenant total square footage? *

occ30- Insured's plans for the vacant property? *

occ31- Describe business operations in detail: ( This needs to be more then a single sentence. It needs to be detailed info. See the examples) *

occ32- Type of business *

Corporation
Partnership
Individual
Franchise
Non-Profit

occ33- Insured's years of experience in this type of business? *

occ34- Insured's time at this location? *

occ35- # of locations *

occ36- Location type *

Residential
Rural
Commercial
Commercial and Residential
Industrial

occ37 - Losses in last 5 years? *

Yes
None in last 5 years

occ38- Describe in detail the loss (this must be more then just an answer of "Hail") *

occ39- Approx. year. (YEAR ONLY) *

occ40- Check all days the Church has services, weddings, funerals or any activities: *

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

occ41- # of days a week they are open? *

1 day
2 days
3 days
4 days
5 days
6 days
7 days
Varies per tenant

occ42- Average opening time *

occ43- Average closing time *

Protection

**AAIS Protective Class

**AAIS Score

**AAIS Description

**Nearest responding fire department *

**Type fire department *

**Drive distance from fire department *

**Drive duration to fire department

**2nd responding fire department

Type 2nd responding fire department

**Drive distance from 2nd fire department

**Drive duration from 2nd fire department

**Nearest fire hydrant *

** Fire hydrant score

**Number of fire hydrants within 1000 feet

**Alternative water source

**Distance to alternative water source.

**Name of water source

P54- Is there Sprinkler system coverage? *

Yes full
Yes partial
None/ Not operational

P55- Sprinkler system have a current tag? *

Yes
None
Unable to determine

56- Describe unable to determine *

P57- Last date of the sprinkler inspection *

Month
Day
Year

58- Sprinkler system under a service contract *

Yes
No service contract

P59A- Does Building(s) have a Standpipe and hose? *

Yes
No

P59B- Standpipe and hose annual inspection current *

Yes
No / no tag

P60- Fire extinguishers location(s) *

None located
Inside units
Exterior of building
Both Inside units and exterior of building(s)

P61- Adequate # of fire ext. in the building(s)? *

Yes tagged and wall mounted
Yes untagged and wall mounted
Yes tagged and not wall mounted
Yes untagged and not wall mounted
No fire extinguishers observed

P62- Fire extinguisher currently tagged *

Currently tagged
Expired Tag
No Tag

P63- Extinguisher tag date *

Month
Day
Year

P64- Smoke detector type *

Hardwired
Battery and Hardwired
Battery
None located

P65- Checked quarterly by *

Owner
Management
Tenant
Maintenance
Other
Not checked quarterly

P66- If Other,Explain *

P67- Records kept on how often smoke detectors are checked *

Yes
No records kept

P68- Does the building(s) have Gas for heating, water heating and/or cooking *

Yes
No gas in building

P70- Type of carbon monoxide detectors *

Battery
Hardwired
Battery and Hardwired
None

P71- Checked quarterly by *

Owner
Management
Tenant
Maintenance
Other
Not checked quarterly

P72- If Other, explain *

P73- Records kept on how often carbon monoxide detectors are checked *

Yes
No records kept

P74A- Does Building(s) have an Alarm system? *

Yes
No

P74B- Type of alarm system *

Monitored burglar alarm
Monitored fire alarm
Monitored fire and burglar alarm
Unmonitored burglar alarm
Unmonitored fire alarm
Unmonitored fire and burglar alarm

P75- Manual pull alarm station *

Yes
No pull alarm

P76- Name of the alarm monitoring company *

P77A- Does Building(s) have a Camera system? *

Yes
No

P77B- Cameras located *

Inside
Outside
Inside and Outside

Flammable

P78- Does Building(s) have flammables? *

Yes
No

Describe the types of flammables stored on the property? *

Approx. # of total gallons?(numbers only) *

Primary location of the flammable materials *

On shelves throughout the shop/warehouse
In a paint mixing room
Fireproof Room
Fireproof Cabinet
In a separate building away from the main building
Outside
Inside

Are "NO Smoking" signs posted in or near the area where the flammables are stored or used *

Yes
No signs observed

Forklift

P79- Does Building(s) have Forklifts? *

Yes
No

# of forklifts on the property? *

Types fuel the forklifts use *

Gasoline
Diesel
Propane
Electric

Where are the forklifts refueled *

Outside the Building from a storage tank
Outside the Building from a UL approved Container
Inside the Building from a UL approved Container
Inside the Building
Outside the Building

Welding

P80- Does Building(s) conduct Welding? *

Yes
No

How often is welding/cutting done? *

Daily
Weekly
Other

Explain when the welding/cutting is done. *

Where is the welding done? *

Inside the building(s)
Outside the building
Inside and outside the building

Are all compressed gas bottles stored in a secured location? *

Yes
No
No extra bottles are stored on the property

Are all acetylene and oxygen bottles stored at least 20 feet apart? *

Yes
No

Are all bottles in carts secured safely by chains or another fastening device? *

Yes
No
No Bottles in Carts

What % of the insured's operations are welding/cutting? *

Painting

P81- Does Building(s) conduct Painting? *

Yes
No

Type of materials sprayed? *

Water/Latex paints or adhesives
Flammable paints or adhesives
Other

Describe what other types of materials are sprayed? *

What type of spray painting booth do they have *

UL approved Paint Booth
Homemade Paint Booth
No Paint Booth

If no paint booth where do they paint *

In a seperate building
Open bay/Shop area
Outside
Other area

Describe where they paint. *

Type of lighting in the spray booth? *

Explosion Proof Lighting
Standard lighting with protective covering
Standard lights no covers
No Lighting

Type of venting system *

Explosion proof vent system with removable filters
Non explosion proof vent system with removable filters
Non explosion proof fan(s) no filters
No Venting System

How does the fan/vent system go to the exterior of the building *

Vented through the roof
Vented through the exterior wall
Not vented directly to the outside

Spray booth equipped with an automatic extinguishing system *

Yes
None present

Date of last inspection *

Month
Day
Year

Woodworking

P82- Does Building(s) conduct Woodworking? *

Yes
No

Describe in detail all the major woodworking equipment. *

Dust collection and distribution system? *

Yes
None present

Where is the dust distributed/stored? *

In a canvas bag inside the building
In a canvas bag outside the building
In a metal hopper
In a trailer
Outside on the ground
Other

Describe where the dust is stored. *

General Liability

Square footage will be auto injected:

Financial

Gross Receipts and Gross Payroll are required if the building owner occupies the building or earns rental income from the property. If the insured is a tenant and owns the business, Gross Receipts ...

None
Gross Receipts
Gross Payroll
Business Interruption (if requested on order)

Did you get the gross receipts? *

Yes
No (This is required)

What are the annual gross receipts? *

Why were you not able to get gross receipts? *

Did you get the business interruption? *

Yes
No

What is the business interruption? *

Why were you not able to get business interruption? *

Did you get the gross payroll? *

Yes
No (required)

What is the gross payroll? *

Why were you not able to get the gross payroll? *

Sidewalk

Type of sidewalks *

Owned by Insured
Public
Both Public and Owned by Insured
None

Condition of sidewalks and walkways *

Excellent
Good
Average
Fair
Poor

Describe the poor sidewalks and/or walkways *

Parking

Parking lot condition *

Excellent
Good
Average
Fair
Poor
None

Describe the poor parking lot condition. *

Exits/Lighting

Adequate # of exits *

Yes
Not enough exits

Describe inadequate number of exits. *

Were all exits marked? *

Exits were marked
Exits were NOT marked

Were all exits unobstructed? *

Exits were unobstructed
Exits were obstructed

Explain all exit obstructions. *

Exit doors equipped with lighted exit signs? *

Lighted exit signs present
Lighted exit signs NOT present
No lighted exit signs needed

Emergency Lighting *

Emergency lighting present
Emergency lighting NOT present
No emergency lighting needed

Was interior lighting adequate? *

Yes
Needs more lighting

Describe the inadequate interior lighting *

Do all exit doors swing to the outside *

Yes
Exterior door(s) swing inside

Panic hardware on doors? *

Panic hardware present
Panic hardware needed
Panic hardware NOT needed

Flooring

Did observed flooring appear unobstructed? *

Yes
Flooring was obstructed

Explain why flooring was obstructed. *

Did observed flooring appear free of moisture? *

Yes
Flooring had moisture present

Explain moisture on floor. *

Did observed flooring appear secure/good condition? *

Yes
Flooring was not secure/good condition

Explain unsecure flooring: *

Steps/Railing

EXTERIOR stairs/steps have 4 or more steps together? *

Four of more together
Less than four together
No exterior stairs/steps

EXTERIOR stairs/steps have railings? *

Railing was present
No railing was present

Do all EXTERIOR stairs/steps that would be used by the public and/or habitational have a solid wall, vertical and/or horizontal bar spacing that is four inches or less? *

Yes
No

What was the spacing? *

5
6
7
8
9
10
11
12
Over 12

Were you able to view the INTERIOR stairs/steps? *

Yes interior stairs
No access to interior stairs
There are no interior stairs

Explain why the INTERIOR stairs/steps were not viewed: *

Did the INTERIOR stairs/steps have 4 or more steps together? *

Four of more together
Less than four together

Did the INTERIOR stairs/steps have railings? *

Railing was present
No railing was present

Do all INTERIOR stairs/steps that would be used by the public and/or habitational have a solid wall, vertical and/or horizontal bar spacing that is four inches or less *

Yes
No

Fencing

Condition of the fence(s) *

No fencing
Excellent
Good
Average
Fair
Poor

Explain the poor fence condition. *

Premises Information

Type of burglar bars *

No burglar bars
Window interior release
Window bolt on
Door interior release

Overall housekeeping *

Premises Good
Premises Fair
Premises Poor
Graffiti/vandalism
High grass brush or weeds
Trees rubbing/touching

Describe the condition *

Explain vandalism/graffiti *

Explain tree rubbing/touching location on building and what building(s) if more than one *

Exposures

**Distance to coast *

Are building(s) prone to flooding? *

Building(s) prone to flooding
Building(s) not prone to flooding

Are there any hazardous exposures from adjacent building(s) or property(s)? *

Hazardous adjacent exposures
No adjacent exposures

Explain adjacent exposures. *

General building(s) updates

Check all updates that apply (if building's over 25 years old it has had some updates) *

Roof
Electrical
Plumbing
Hvac
None

Years since last roof update *

1-5 years
6-10 years
11-15 years
16-20 years
Over 20 years
Done as needed
Unknown to insured

Roof updates *

Complete replacement
Partial replacement
Patched/Repaired

Roof Notes (if needed)

**Approx. Year Built

Electrical panel type. ( Must have photos of panel and label) *

Other panel type *

Explain why Panel(s) were not accessible. *

Electrical wiring *

Romex
Conduit
Romex and Conduit
Knob and Tube
None observed

Wire type *

Copper
Aluminum
Aluminum Pigtail
Aluminum CO/ALR

Years since last electrical updates

1-5 years
6-10 years
11-15 years
16-20 years
Over 20 years
Done as needed
Unknown to insured

Electrical condition *

Good
Average
Poor
Uncontrolled hazards

Explain condition/hazard *

Electrical notes (if needed)

Hvac type

Years since last hvac updates *

Hvac notes (if needed)

Plumbing type *

Copper
Galvanized
Copper and Galvanized
PVC
PEX (plastic flex tubing)
None observed

Years since last plumbing update

1-5 years
6-10 years
11-15 years
16-20 years
Over 20 years
Done as needed
Unknown to insured

Building(s)

Blg1- Additional building(s) / structure(s) *

Additional buildings present
No additional buildings on property

Blg2- Are there additional building(s) SFO *

Additional buildings present
No additional buildings on property

Did order request individual values for each building or are there different types of occupancies? (See Example) *

Yes
No

Are all the buildings the same year and construction including roofing, electrical, plumbing and heating as Building 1? *

All buildings ARE the same size year const electrical and plumbing
All buildings are NOT the same size year const electrical and plumbing

If answer is "no" to the above question, please specify other building's electrical, plumbing and heating if there is any: *

How many additional Building(s) *

Number of additional buildings *

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