Edit Form - Drag N' Drop FormBuilder

Package Add-on

This registration form is now offline

Supplement forms
Occupancy *
occ17- Swimming pool *
- Yes
- No
occ18- Select all that apply *
- None
- Restaurant
- Convenience Store
- Nightclub
- Daycare
- Playground
- Laundromat/Dry cleaners
- Apartment
- Hotel/Motel
- Cannabis
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
Additional forms (if needed) *
- BBQ Pit
- Builders Risk
- Cooking
- Playground
- Swimming Pool
- Inland Marine
- Food Storage
- Liquor Liability
Apartment Form
APMT-# of units *
APMT-Approx. % of occupancy *
APMT-% owner occupied *
APMT-Any HUD, or subsidized housing *
- HUD housing
- Subsidized housing
- None
APMT-% of HUD housing *
APMT-% of subsidized housing *
APMT-Any student or senior housing *
- Student Housing
- Senior Housing
- None
APMT-% of student housing *
APMT-% of senior housing *
APMT-Any common hallways *
- Yes
- No common hallways
APMT-Hallways equipped with lighted exit signs *
- Yes
- No lighted exit signs in common hallways
APMT- Exterior doors equipped with peep holes or windows near the door *
- Yes
- No
APMT - Exterior doors on each unit equipped with keyless deadbolts *
- Yes
- No keyless deadbolts
- Not all units had keyless deadbolts
APMT-Are there sliding glass doors *
- Yes
- No sliding glass doors
APMT - Are all entry door locks changed after each vacancy *
- Yes
- No
APMT- # of laundry rooms *
APMT- # of washers *
APMT- # of electric dryers *
APMT- # of gas dryers *
BBQ Pit
BBQ- # of BBQ pits *
BBQ - BBQ pit built into the building *
- Yes
- No
BBQ : Approx. distance from the building *
BBQ : What is the construction of the barbeque pit(s)? *
BBQ - Type fuel for Pit(s) *
- Wood
- Natural Gas
- Propane Gas
- Electric
BBQ - Is gas used to start the fire *
- Yes
- No
BBQ - How long is the gas used *
BBQ - How's temperature controlled in the Pit *
- Drop down lid(s)
- Damper
- Thermostat
BBQ - Method is used to clean the Pit(s) *
BBQ - When barbeque pit is turned off, how is the fire extinguished *
BBQ - Are extinguishers accessible to the bbq pit *
- Yes
- No
Builders Risk
BR - The insured is: *
- Owner
- Developer
- General Contractor
- Subcontractor
BR - Does the insured use subcontractors *
- Yes
- No subcontractors used
BR : Does the insured get certificates of insurance from each subcontractor? *
- Yes
- No COI's from Subcontractors
BR - Type of project/job at the location *
- New Construction
- Renovation/Remodel
BR - Date the construction/job begin *
- Month
- Day
- Year
BR - Estimated date of completion *
- Month
- Day
- Year
BR - Are there delays in the work schedule *
- Yes
- No delays in work
BR - Describe the delays in the work schedule. *
BR - Does the existing building have any damage *
- Yes
- No existing damage
BR - Describe the damage to the existing building. *
BR - Describe in detail the type of renovations/Remodeling. *
BR - Approx. what % of the project/job has been completed *
BR - Projected cost of the project *
BR - How often is the scrap/debris removed *
- Daily
- Weekly
- Bi-Weekly
- Monthly
- When completed
- No Debris
XX - Project/job fenced *
- Yes
- No fence needed
BR - Type of fencing *
- No fencing needed
- Chain link
- Wrought Iron
- Barbed Wire
- Wood
- Metal
- Other
BR - Describe other fencing *
BR - Watchman or security service provided *
- Yes
- No security service
BR - Stability of the neighborhood/area *
- Stable
- Declining Improving
Convenience Store
Conv - Injected from Comm form data *
- Building Owner Only
- Building Owner and Occupies the Building
- Building Owner and Occupies Building with Tenants
- Tenant
- Land Owner Only
Conv - Cooking done in the convenience store *
- Yes
- No cooking done
Conv - Any beer, wine and/or liquor sales *
- Yes
- No beer wine or liquor sales
Conv - Type of liquor license *
- On Premises
- Off Premises
Conv - Inside store sales (excluding gas) *
Conv - Total gross sales for conv. store (No gas sales included) *
Conv - Does the insured sell lotto tickets *
- Yes
- No lottery sales
Conv - Do they have video gaming machines *
- Yes
- No video gaming machines
Conv - Gasoline/Diesel sales *
- Self-service pumps
- Full-service pumps
- Self-service and Full-service pumps
- No fuel pumps
Conv - Total number of self service pumps *
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20 plus
Conv - Total number of full service pumps *
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20 plus
Conv - All pumps under cover *
- All pumps covered
- Partial pumps covered
- No pumps covered
Conv - Location of the emergency fuel pump shutoff switch *
- No emergency fuel shutoff
- Inside Building
- Outside Building
- Inside and Outside the building
Conv - Average distance fuel pumps are from the building(s) *
Conv - All pumps adequately protected from vehicular damage *
- Yes pumps are protected
- No pump protection
Conv - Fuel tanks location *
- Underground tanks
- Above ground tanks
- Above ground and underground tanks
Conv - Above ground fuel tanks adequately protected *
- Yes
- No protection
Conv - Annual gallons of gasoline sold *
Conv - Approx. annual sales of gasoline sold *
Conv - LPG (propane) sold *
- Yes
- No LPG (Propane) sold
Conv - Do they fill LGP (propane) tanks *
- Yes
- No LPG (propane) bottles filled
Conv - # of employees licensed to dispense LPG (propane) *
Conv - Approx. # gallons in the LPG (propane) main storage tank *
Conv - All LPG tanks fenced and protected from the general public *
- Yes
- No fence or protection
Conv - Approx. # of gallons of LPG sold annually *
Conv - All LPG tanks stored in a locked cage *
- Yes
- No
Conv - Are all LPG cages adequately protected from vehicular damage *
- Yes
- No protection
Conv - Automatic car wash *
- Yes
- No Automatic carwash
Conv - Approx. car wash annual sales *
Conv - Do they have protective concrete wheel stops and/or metal barriers in the front of the store to protect from vehicle entry *
- Yes
- No barrier protection
Conv - Do they have slip mats at all beverage stations *
- Yes
- No Slip mats present
- No beverage area
Conv - Do they have a UL approved safe *
- Yes
- No
COOKING FORM 1
Cook - This is injected from another form. *
- Building Owner Only
- Building Owner and Occupies Building
- Building Owner and Occupies Building with Tenants
- Tenant
- Land Owner only
Cook : Does the building owner run the cooking business? *
- Yes
- No
Cook - Give a detailed description of the cooking operation *
Cook - Approx. seating capacity *
Give a percentage breakdown of the receipts
Cook - % of liquor/beer receipts *
Cook - % of food receipts *
Cook - % of catering receipts *
Cook - % of other receipts *
Cook - Total % of receipts *
Give a breakdown of the cooking equipment.
Cook - # of Gas ovens. *
Cook - # of electric ovens *
Cook - # of gas grills *
Cook - # of electric grills *
Cook - # of gas deep fryers *
Cook - # of electric deep fryers *
Cook - Are the deep fryer(s) equipped with a shutdown thermostat *
- Yes
- No shutdown thermostat
Cook - Are the deep fryer(s) separated at least 16 inches from an open flame or have a 12 inch high metal divider baffle installed between the fryer and the open flame *
- Yes
- No
Cook - # of broilers *
Cook - # of woks *
Cook - # of charbroilers *
Cook - # of stoves *
Cook - Commercial bbq pit *
- Yes commercial bbq pit
- No commercial bbq pit
Vent Hood Exhaust System
Cook - Exhaust vent hood provided for all grease/smoke producing equipment *
- Yes
- No vent hood
Cook - Exhaust hood cleaned by a professional firm at least semi-annually *
- Yes
- No
Cook - Baffle type filters at a 45 degree angle in the exhaust hood (no wire mesh) *
- Yes
- No
Cook - How often are the filters cleaned *
- Daily
- Weekly
- Monthly
- Quarterly
- As needed
Cook - Vent/Exhaust hood light *
- Covered lighting
- Lighting no covers
- No lights in hood
AES Automatic Extinguishing System
Cook - Is there a automatic extinguishing system (AES) *
- Yes
- No Automatic extinguishing system
- No Automatic extinguishing system needed
Cook : Name of AES manufacture? *
Cook - Automatic extinguisher system have a CURRENT tag with an inspection date *
- Yes
- No current inspection tag
Cook - Date of AES last inspection *
- Month
- Day
- Year
Cook - Grease/smoke producing cooking surfaces covered by the AES *
- Yes
- No
Cook - Excessive grease buildup on the filters, cooking equipment, or floors *
- Yes
- No
Cook - Explain the excessive grease buildup *
Cook - Is there at least one dry chemical extinguisher rated a minimum of a 2A10BC *
- Yes
- No 2A10BC extinguisher in kitchen
Cook - Did the Minimum rated 2A:10BC extinguisher have a current tag *
- Yes
- No current inspection tag
Cook - What was the last date of inspection on the 2A:10BC extinguisher *
- Month
- Day
- Year
Cook - One Class K extinguisher (Silver tank for grease fires) *
- Yes
- No class K extinguisher
Cook - Did the Class K extinguisher have a current tag *
- Yes
- No current inspection tag
Cook : What was the last date of inspection on the Class K extinguisher? *
- Month
- Day
- Year
Cook - Kitchen housekeeping in good condition *
- Yes
- No
Cook - Additional cooking business on property. *
- Yes I need an additional form
- No other cooking on the property
Cooking Form 2
Cook2 - This is injected from another form. *
- Building Owner Only
- Building Owner and Occupies Building
- Building Owner and Occupies Building with Tenants
- Tenant
- Land Owner only
Cook2 : Does the building owner run the cooking business? *
- Yes
- No
Cook2 - Give a detailed description of the cooking operation *
Cook2 - Approx. seating capacity *
Cook2 - % of liquor/beer receipts *
Cook2 - % of food receipts *
Cook2 - % of catering receipts *
Cook2 - % of other receipts *
Cook2 - Total % of receipts *
Cook2 - # of Gas ovens. *
Cook2 - # of electric ovens *
Cook2 - # of gas grills *
Cook2 - # of electric grills *
Cook2 - # of gas deep fryers *
Cook2 - # of electric deep fryers *
Cook2 - Are the deep fryer(s) equipped with a shutdown thermostat *
- Yes
- No shutdown thermostat
Cook2 - Are the deep fryer(s) separated at least 16 inches from an open flame or have a 12 inch high metal divider baffle installed between the fryer and the open flame *
- Yes
- No
Cook2 - # of broilers *
Cook2 - # of woks *
Cook2 - # of charbroilers *
Cook2 - # of stoves *
Cook2 - Commercial bbq pit *
- Yes commercial bbq pit
- No commercial bbq pit
Cook2 - Approved exhaust vent hood system provided for all grease/smoke producing equipment *
- Yes
- No vent hood
Cook2: Exhaust hood system cleaned by a professional firm at least semi-annually *
- Yes
- No
Cook2 - Baffle type filters at a 45 degree angle in the exhaust hood (no wire mesh) *
- Yes
- No
Cook2 - How often are the filters cleaned *
- Daily
- Weekly
- Monthly
- Quarterly
- As needed
Cook2 - Vent/Exhaust hood light *
- Covered lighting
- Lighting no covers
- No lights in hood
Cook2 - Is there a automatic extinguishing system (AES) *
- Yes
- No Automatic extinguishing system
- No Automatic extinguishing system needed
Cook2 : Name of AES manufacture? *
Cook2 - Automatic extinguisher system have a CURRENT tag with an inspection date *
- Yes
- No current inspection tag
Cook2 - Date of AES last inspection *
- Month
- Day
- Year
Cook2 - Grease/smoke producing cooking surfaces covered by the AES *
- Yes
- No
Cook2 - Excessive grease buildup on the filters, cooking equipment, or floors *
- Yes
- No
Cook2 - Explain the excessive grease buildup *
Cook2 - Is there at least one dry chemical extinguisher rated a minimum of a 2A10BC *
- Yes
- No 2A10BC extinguisher in kitchen
Cook2 - Did the Minimum rated 2A:10BC extinguisher have a current tag *
- Yes
- No current inspection tag
Cook2 - What was the last date of inspection on the 2A:10BC extinguisher *
- Month
- Day
- Year
Cook2 - One Class K extinguisher (Silver tank for grease fires) *
- Yes
- No class K extinguisher
Cook2 - Did the Class K extinguisher have a current tag *
- Yes
- No current inspection tag
Cook2 : What was the last date of inspection on the Class K extinguisher? *
- Month
- Day
- Year
Cook2 - Kitchen housekeeping in good condition *
- Yes
- No
Cook2 - Additional cooking business on property. *
- Yes I need an additional form
- No other cooking on the property
Cooking Form 3
Cook3 - This is injected from another form. *
- Building Owner Only
- Building Owner and Occupies Building
- Building Owner and Occupies Building with Tenants
- Tenant
- Land Owner only
Cook3 : Does the building owner run the cooking business? *
- Yes
- No
Cook3 - Give a detailed description of the cooking operation *
Cook3 - Approx. seating capacity *
Cook3 - % of liquor/beer receipts *
Cook3 - % of food receipts *
Cook3 - % of catering receipts *
Cook3 - % of other receipts *
Cook3 - Total % of receipts *
Cook3 - # of Gas ovens. *
Cook3 - # of electric ovens *
Cook3 - # of gas grills *
Cook3 - # of electric grills *
Cook3 - # of gas deep fryers *
Cook3 - # of electric deep fryers *
Cook3 - Are the deep fryer(s) equipped with a shutdown thermostat *
- Yes
- No shutdown thermostat
Cook3 - Are the deep fryer(s) separated at least 16 inches from an open flame or have a 12 inch high metal divider baffle installed between the fryer and the open flame *
- Yes
- No
Cook3 - # of broilers *
Cook3 - # of woks *
Cook3 - # of charbroilers *
Cook3 - # of stoves *
Cook3 - Commercial bbq pit *
- Yes commercial bbq pit
- No commercial bbq pit
Cook3 - Exhaust vent hood provided for all grease/smoke producing equipment *
- Yes
- No vent hood
Cook3 - Exhaust hood cleaned by a professional firm at least semi-annually *
- Yes
- No
Cook3 - Baffle type filters at a 45 degree angle in the exhaust hood (no wire mesh) *
- Yes
- No
Cook3 - How often are the filters cleaned *
- Daily
- Weekly
- Monthly
- Quarterly
- As needed
Cook3 - Vent/Exhaust hood light *
- Covered lighting
- Lighting no covers
- No lights in hood
Cook3 - Is there a automatic extinguishing system (AES) *
- Yes
- No Automatic extinguishing system
- No Automatic extinguishing system needed
Cook3 : Name of AES manufacture? *
Cook3 - Automatic extinguisher system have a CURRENT tag with an inspection date *
- Yes
- No current inspection tag
Cook3 - Date of AES last inspection *
- Month
- Day
- Year
Cook3 - Grease/smoke producing cooking surfaces covered by the AES *
- Yes
- No
Cook3 - Excessive grease buildup on the filters, cooking equipment, or floors *
- Yes
- No
Cook3 - Explain the excessive grease buildup *
Cook3 - Is there at least one dry chemical extinguisher rated a minimum of a 2A10BC *
- Yes
- No 2A10BC extinguisher in kitchen
Cook3 - Did the Minimum rated 2A:10BC extinguisher have a current tag *
- Yes
- No current inspection tag
Cook3 - What was the last date of inspection on the 2A:10BC extinguisher *
- Month
- Day
- Year
Cook3 - One Class K extinguisher (Silver tank for grease fires) *
- Yes
- No class K extinguisher
Cook3 - Did the Class K extinguisher have a current tag *
- Yes
- No current inspection tag
Cook3 : What was the last date of inspection on the Class K extinguisher? *
- Month
- Day
- Year
Cook3 - Kitchen housekeeping in good condition *
- Yes
- No
Cook3 - Additional cooking business on property. *
- Yes I need an additional form
- No other cooking on the property
Cooking Form 4
Cook4 - This is injected from another form. *
- Building Owner Only
- Building Owner and Occupies Building
- Building Owner and Occupies Building with Tenants
- Tenant
- Land Owner only
Cook4 : Does the building owner run the cooking business? *
- Yes
- No
Cook4 - Give a detailed description of the cooking operation *
Cook4 - Approx. seating capacity *
Cook4 - % of liquor/beer receipts *
Cook4 - % of food receipts *
Cook4 - % of catering receipts *
Cook4 - % of other receipts *
Cook4 - Total % of receipts *
Cook4 - # of Gas ovens. *
Cook4 - # of electric ovens *
Cook4 - # of gas grills *
Cook 4- # of electric grills *
Cook4 - # of gas deep fryers *
Cook4 - # of electric deep fryers *
Cook4 - Are the deep fryer(s) equipped with a shutdown thermostat *
- Yes
- No shutdown thermostat
Cook4 - Are the deep fryer(s) separated at least 16 inches from an open flame or have a 12 inch high metal divider baffle installed between the fryer and the open flame *
- Yes
- No
Cook4 - # of broilers *
Cook4 - # of woks *
Cook4 - # of charbroilers *
Cook4 - # of stoves *
Cook4 - Commercial bbq pit *
- Yes commercial bbq pit
- No commercial bbq pit
Cook4 - Exhaust vent hood provided for all grease/smoke producing equipment *
- Yes
- No vent hood
Cook4 - Exhaust hood cleaned by a professional firm at least semi-annually *
- Yes
- No
Cook4 - Baffle type filters at a 45 degree angle in the exhaust hood (no wire mesh) *
- Yes
- No
Cook4 - How often are the filters cleaned *
- Daily
- Weekly
- Monthly
- Quarterly
- As needed
Cook4 - Vent/Exhaust hood light *
- Covered lighting
- Lighting no covers
- No lights in hood
Cook4 - Is there a automatic extinguishing system (AES) *
- Yes
- No Automatic extinguishing system
- No Automatic extinguishing system needed
Cook4 : Name of AES manufacture? *
Cook4 - Automatic extinguisher system have a CURRENT tag with an inspection date *
- Yes
- No current inspection tag
Cook4 - Date of AES last inspection *
- Month
- Day
- Year
Cook4 - Grease/smoke producing cooking surfaces covered by the AES *
- Yes
- No
Cook4 - Excessive grease buildup on the filters, cooking equipment, or floors *
- Yes
- No
Cook4 - Explain the excessive grease buildup *
Cook4 - Is there at least one dry chemical extinguisher rated a minimum of a 2A10BC *
- Yes
- No 2A10BC extinguisher in kitchen
Cook4 - Did the Minimum rated 2A:10BC extinguisher have a current tag *
- Yes
- No current inspection tag
Cook4 - What was the last date of inspection on the 2A:10BC extinguisher *
- Month
- Day
- Year
Cook4 - One Class K extinguisher (Silver tank for grease fires) *
- Yes
- No class K extinguisher
Cook4 - Did the Class K extinguisher have a current tag *
- Yes
- No current inspection tag
Cook4 : What was the last date of inspection on the Class K extinguisher? *
- Month
- Day
- Year
Cook4 - Kitchen housekeeping in good condition *
- Yes
- No
Cook4 - Additional cooking business on property. *
- Yes I need an additional form
- No other cooking on the property
Cooking Form 5
Cook5 - This is injected from another form. *
- Building Owner Only
- Building Owner and Occupies Building
- Building Owner and Occupies Building with Tenants
- Tenant
- Land Owner only
Cook5 : Does the building owner run the cooking business? *
- Yes
- No
Cook5 - Give a detailed description of the cooking operation *
Cook5 - Approx. seating capacity *
Cook5 - % of liquor/beer receipts *
Cook5 - % of food receipts *
Cook5 - % of catering receipts *
Cook5 - % of other receipts *
Cook5 - Total % of receipts *
Cook5 - # of Gas ovens. *
Cook5 - # of electric ovens *
Cook5 - # of gas grills *
Cook5 - # of electric grills *
Cook5 - # of gas deep fryers *
Cook5 - # of electric deep fryers *
Cook5 - Are the deep fryer(s) equipped with a shutdown thermostat *
- Yes
- No shutdown thermostat
Cook5 - Are the deep fryer(s) separated at least 16 inches from an open flame or have a 12 inch high metal divider baffle installed between the fryer and the open flame *
- Yes
- No
Cook5 - # of broilers *
Cook5 - # of woks *
Cook5 - # of charbroilers *
Cook5 - # of stoves *
Cook5 - Commercial bbq pit *
- Yes commercial bbq pit
- No commercial bbq pit
Cook5 - Exhaust vent hood provided for all grease/smoke producing equipment *
- Yes
- No vent hood
Cook5 - Exhaust hood cleaned by a professional firm at least semi-annually *
- Yes
- No
Cook5 - Baffle type filters at a 45 degree angle in the exhaust hood (no wire mesh) *
- Yes
- No
Cook5 - How often are the filters cleaned *
- Daily
- Weekly
- Monthly
- Quarterly
- As needed
Cook5 - Vent/Exhaust hood light *
- Covered lighting
- Lighting no covers
- No lights in hood
Cook5 - Is there a automatic extinguishing system (AES) *
- Yes
- No Automatic extinguishing system
- No Automatic extinguishing system needed
Cook5 : Name of AES manufacture? *
Cook5 - Automatic extinguisher system have a CURRENT tag with an inspection date *
- Yes
- No current inspection tag
Cook5 - Date of AES last inspection *
- Month
- Day
- Year
Cook5 - Grease/smoke producing cooking surfaces covered by the AES *
- Yes
- No
Cook5 - Excessive grease buildup on the filters, cooking equipment, or floors *
- Yes
- No
Cook5 - Explain the excessive grease buildup *
Cook5 - Is there at least one dry chemical extinguisher rated a minimum of a 2A10BC *
- Yes
- No 2A10BC extinguisher in kitchen
Cook5 - Did the Minimum rated 2A:10BC extinguisher have a current tag *
- Yes
- No current inspection tag
Cook5 - What was the last date of inspection on the 2A:10BC extinguisher *
- Month
- Day
- Year
Cook5 - One Class K extinguisher (Silver tank for grease fires) *
- Yes
- No class K extinguisher
Cook5 - Did the Class K extinguisher have a current tag *
- Yes
- No current inspection tag
Cook5 : What was the last date of inspection on the Class K extinguisher? *
- Month
- Day
- Year
Cook5 - Kitchen housekeeping in good condition *
- Yes
- No
Cook5 - Additional cooking business on property. *
- Yes I need an additional form
- No other cooking on the property
Cooking Form 6
Cook6 - This is injected from another form. *
- Building Owner Only
- Building Owner and Occupies Building
- Building Owner and Occupies Building with Tenants
- Tenant
- Land Owner only
Cook6 : Does the building owner run the cooking business? *
- Yes
- No
Cook6 - Give a detailed description of the cooking operation *
Cook6 - Approx. seating capacity *
Cook6 - % of liquor/beer receipts *
Cook6 - % of food receipts *
Cook6 - % of catering receipts *
Cook6 - % of other receipts *
Cook6 - Total % of receipts *
Cook6 - # of Gas ovens. *
Cook6 - # of electric ovens *
Cook6 - # of gas grills *
Cook6 - # of electric grills *
Cook6 - # of gas deep fryers *
Cook6 - # of electric deep fryers *
Cook6 - Are the deep fryer(s) equipped with a shutdown thermostat *
- Yes
- No shutdown thermostat
Cook6 - Are the deep fryer(s) separated at least 16 inches from an open flame or have a 12 inch high metal divider baffle installed between the fryer and the open flame *
- Yes
- No
Cook6 - # of broilers *
Cook6 - # of woks *
Cook6 - # of charbroilers *
Cook6 - # of stoves *
Cook6 - Commercial bbq pit *
- Yes commercial bbq pit
- No commercial bbq pit
Cook6 - Exhaust vent hood provided for all grease/smoke producing equipment *
- Yes
- No vent hood
Cook6 - Exhaust hood cleaned by a professional firm at least semi-annually *
- Yes
- No
Cook6 - Baffle type filters at a 45 degree angle in the exhaust hood (no wire mesh) *
- Yes
- No
Cook6 - How often are the filters cleaned *
- Daily
- Weekly
- Monthly
- Quarterly
- As needed
Cook6 - Vent/Exhaust hood light *
- Covered lighting
- Lighting no covers
- No lights in hood
Cook6 - Is there a automatic extinguishing system (AES) *
- Yes
- No Automatic extinguishing system
- No Automatic extinguishing system needed
Cook6 : Name of AES manufacture? *
Cook6 - Automatic extinguisher system have a CURRENT tag with an inspection date *
- Yes
- No current inspection tag
Cook6 - Date of AES last inspection *
- Month
- Day
- Year
Cook6 - Grease/smoke producing cooking surfaces covered by the AES *
- Yes
- No
Cook6 - Excessive grease buildup on the filters, cooking equipment, or floors *
- Yes
- No
Cook6 - Explain the excessive grease buildup *
Cook6 - Is there at least one dry chemical extinguisher rated a minimum of a 2A10BC *
- Yes
- No 2A10BC extinguisher in kitchen
Cook6 - Did the Minimum rated 2A:10BC extinguisher have a current tag *
- Yes
- No current inspection tag
Cook6 - What was the last date of inspection on the 2A:10BC extinguisher *
- Month
- Day
- Year
Cook6 - One Class K extinguisher (Silver tank for grease fires) *
- Yes
- No class K extinguisher
Cook6 - Did the Class K extinguisher have a current tag *
- Yes
- No current inspection tag
Cook6 : What was the last date of inspection on the Class K extinguisher? *
- Month
- Day
- Year
Cook6 - Kitchen housekeeping in good condition *
- Yes
- No
Daycare
1 Daycare - This is injected from another form *
- Building Owner Only
- Building Owner and Occupies the Building
- Building Owner and Occupies Building with Tenants
- Tenant
- Land Owner Only
Daycare : Do they have a playground? *
- Yes
- No playground present
Daycare - # of children licensed for *
Daycare - # of children currently enrolled *
Daycare - Daily average attendance of children *
Daycare - Youngest age of children they take care of *
Daycare - Oldest age of children they take care of *
Daycare - Are drop-ins accepted *
- Drop ins accepted
- No drop ins accepted
Daycare - Are children separated by ages *
- Yes
- Not separated by age
Daycare - They comply with state mandated requirements *
- Yes
- No
Daycare - Subsidized programs for children's tuition *
- Yes
- No
Daycare - Do they have procedures in place to prevent unauthorized pickup of children *
- Yes
- No
Daycare - Any pickup and/or drop off of children *
- Yes
- No
Daycare - # of vehicles they have *
Daycare - Field trips or other types of trips taken *
- Yes field trips
- No field trips
Daycare - How often do they take field or other trips *
Daycare : Type of activities do they go to on the field trips *
Daycare - Owners and staff have CPR and first aid training *
- Yes
- No CPR training
Daycare - Distance they travel on the field trips *
Daycare - Are vehicles owned by the owner or staff used for transportation for off premises *
- Yes
- No
Daycare - Procedures in place for handling ill or abusive children *
- Yes
- No
Daycare - Do they accept handicapped or special need children *
- Yes
- No
Daycare - Any handicapped or special needs currently enrolled *
- Yes
- No
Daycare - Describe handicapped or special needs children *
Daycare - Sign-in and out program in place for pickup/drop-off *
- Yes
- No
Daycare - # of staff employees *
Daycare - How often are fire drills conducted *
- Monthly
- Quarterly
- Never
Daycare - Does the staff administer any medication *
- Yes
- No
Daycare - Describe how medication is administered *
Daycare - Are medications kept in a locked cabinet, locked container, or in the refrigerator if needed *
- Yes
- No
Daycare - Do they prepare meals for the children *
- Yes
- No
Daycare - What type of kitchen equipment did they have for cooking meals *
- Domestic Kitchen
- Commercial Kitchen
- No Kitchen Equipment
Daycare - Are there any late night or overnight services provided *
- Yes
- No
Daycare - Explain the late night or overnight services in detail *
Daycare - Any dancing, karate, gymnastics or other activity taught on the premises *
- Yes
- No
Daycare - Describe in detail the dancing, karate, gymnastics, or other activities *
Duplex / Triplex
Duplex/Triplex - What Percent of Occupancy *
Duplex/Triplex - Exterior door equipped with peep holes *
- Yes
- No peep holes
Duplex/Triplex - Are exterior doors equipped with keyless deadbolts *
- Yes
- No keyless deadbolts
Food Storage / Sanitation
Food Storage - Are all food cold storage units internal temperatures <= 45°F ( 7 °C) *
- Yes
- No
Food Storage - Are all food hot storage units internal temperatures at or above 140 degrees Fahrenheit or 60 degrees centigrade *
- Yes
- No
Food Storage - Is a licensed pest control service company being used *
- Yes
- No
Food Storage : How often does the pest control company service the property *
- Weekly
- Bi Weekly
- Monthly
- Quarterly
- Semi Annually
- Annually
Food Storage : How is the pest control done *
Food Storage - Are food containers properly covered with lids that are impervious and non-absorbent *
- Yes
- No
Food Storage - Is the ice machine(s) clean and sanitary *
- Yes
- No
Food Storage - Is it common practice for all ice dispensing to be done with a self dispensing machine, a scoop, tongs, or other utensils and stored in a way that protects the ice from contamination... *
- Yes
- No
Food Storage - Do they have a dishwashing machine(s) *
- Yes
- No
Food Storage - Explain how dishes are cleaned *
Food Storage - Is hot water used for cleaning plates, dishes and utensils at an approximate temperature of 170°F or 77°C *
- Yes
- No
Food Storage : If hot water isn't solely used for cleaning plates, dishes and utensils, are they using any approved cleaning solutions mixed with the water? *
- Yes
- No
Hotel/Motel
Hotel/Motel - Is there a laundry room *
- Yes
- No laundry room
Hotel/Motel - Is there a swimming pool *
- Yes
- No swimming pool
Hotel/Motel - Is there a bar/lounge *
- Yes
- No bar or lounge
Hotel/Motel - Does the hotel manage the bar/lounge *
- Yes
- No
Hotel/Motel : Is there a restaurant? *
- Yes
- No restaurant
Hotel/Motel - Does the hotel manage the restaurant *
- Yes
- Restaurant not managered by hotel
Gross Receipts
Hotel/Motel - What are the hotel gross receipts *
Hotel/Motel - What are the restaurant gross receipts *
Hotel/Motel - What are the bar gross receipts *
Room Rentals
Hotel/Motel - How are the rooms rented out *
- Hourly
- Daily
- Weekly
- Monthly
Hotel/Motel - What was the average room rate *
Hotel/Motel - What is the total number of rooms *
Hotel/Motel - Is there an owner or manager's living quarters *
- Yes
- No manager living quarters
Security Information
Hotel/Motel - Do they have security guards *
- Yes
- No security guard
Hotel/Motel - Are the security guards armed *
- Yes
- Security not armed
Hotel/Motel - Do they have courtesy patrol *
- Yes
- No courtesy patrol
Hotel/Motel - Are there any sliding glass doors *
- Yes
- No sliding glass doors
Hotel/Motel - Are all sliding doors equipped with locking pins or Charlie bars *
- Yes
- No locking pins or Charlie bars
Hotel/Motel - Are all exterior door equipped with peep holes *
- Yes
- No peepholes
Hotel/Motel - Do they use door keys or electronic card keys *
- Door keys
- Electronic card keys
Inland Marine
Inland Marine - Type of operation *
- Contractor equipment
- Electronic data processing equipment
- Cargo coverage for property in transit
- None
Equipment Information
Inland Marine - Did you attach a list of equipment with make, model, and s/n. *
- Yes
- No
Inland Marine - Where is the equipment stored at night *
- On the jobsite
- Company Shop Building
- Company fenced in storage lot
- Barn
- Garage
- Depends on jobsite location
- Canopy or Awning
Inland Marine - What type of protection do they have *
- Fencing
- Security Guards
- Security Lights
- Security Cameras
- None
- Other
Inland Marine - Describe the other type of protection *
Inland Marine - Are keys removed from all equipment when not in use *
- Yes
- No
Inland Marine - Where are the keys kept *
Inland Marine - Does the equipment have electronic GPS tracking devices *
- Yes
- No
Inland Marine - List all equipment that has a GPS tracker on it *
Inland Marine - How is the equipment transported to a jobsite *
- Truck and Trailer
- Farm use only
- Driven
- Not Transported
- Stationary Equipment
Inland Marine - Is equipment leased to others *
- Yes
- No
Inland Marine - Does the insured supply the operator for the equipment leased *
- Yes
- No
Inland Marine - Do company name and ID# appear on the equipment *
- Yes
- No
Inland Marine - Are all serial numbers recorded and kept on file *
- Yes
- No
Inland Marine - Who maintains the equipment *
Inland Marine - Do they have a maintenance agreement *
- Yes
- No
Inland Marine - Are appropriate fire extinguishers in place *
- Yes
- No
Inland Marine - Are the fire extinguishers maintained annually by a professional firm *
- Yes
- No
Inland Marine - What type of cargo/materials are being transported *
Inland Marine - Are there any hazardous or flammables being transported *
- Yes
- No
Inland Marine - How is the cargo being transported by *
- Insured Vehicles
- Private Carrier
- Common Carrier
- Other
Inland Marine - Describe other type of transportation *
Inland Marine - Approximate distance to destination *
Inland Marine - Approximate value of shipment *
Inland Marine - Are identifying data or serial numbers kept *
- Yes
- No
Inland Marine - Does cargo have permanent identification numbers *
- Yes
- No
Laundry / Dry cleaner
Laundry - Is this location a Laundrymat, Dry cleaners or Hotel *
- Laundry room for Apartment or Hotel
- Laundrymat
- Dry Cleaners
- Laundrymat and or Dry Cleaners
- None on the property
Laundry - Type of laundry room *
- Residents only
- Guest laundry and Maid service laundry
- Guest laundry only
- Maid service laundry only
Laundry - # of laundry rooms on the property *
Laundry - # of washers *
Laundry - # of electric dryers *
Laundry - # of gas dryers *
Laundry - How are the dryers vented *
- Wall vents
- Roof vents
- Wall and roof vents
- Not Vented
Laundry - Type of cleaning fluids are use in the dry cleaning process *
- Perchlorethylene
- Naptha
- None
- Other
Laundry - Other type of chemical is used for dry cleaning *
Laundry : Do they have any bulk storage of naptha? *
- Yes
- No
Laundry : Approximate total quantity of dry cleaning chemical's stored on the property? *
Laundry - Do they have an attendant on duty during hours of operation *
- Yes
- No
Liquor Liability
LL - Is this policy for a special event *
- Yes
- No
LL - Are the facilities available for banquets, receptions, and/or private affairs *
- Yes
- No
LL - # of annual functions *
LL - Type of functions do they have *
LL - Does the insured have more than one business operation at this location *
- Yes
- No
LL - Describe in detail the business operations *
LL - Type of food service do they provide *
- On Premises
- Off Premises
- None
LL - Type of alcohol service do they provide *
- On premises
- Off premises
- On and off premises
Provide breakdown of receipts for each that apply include a 0 for none.
LL - Food sales *
LL - Alcohol sales *
LL - Types of entertainment are on the premises *
- DJ
- Band
- Stage Floor show
- Jukebox
- Comedian
- Karaoke
- Exotic dancing
- Solo vocalist
- Other
- None
LL - Describe other type of entertainment *
LL - What types of music do they play *
- Jazz
- Country
- Top 40
- Hard rock
- Classic rock
- Soft rock
- R & B
- Alternative
- Rap
- No Music
LL - Do they have a valid liquor license *
- Yes
- No
LL - Exact name on the License *
LL - License Number *
LL - Are employees allowed to consume alcohol during their hours of employment *
- Yes
- No
- No Employees
LL - Is the property within 5 miles of a college/university *
- Yes
- No
LL - What is the average age of the patrons *
- Under 21
- 21-25
- 26-30
- 31+
LL - Do they offer drink incentives *
- Yes
- No
LL - Are persons under the legal drinking age allowed on the premises after 10:00 pm *
- Yes
- No
LL - Do they have bouncers or door persons *
- Yes
- No
LL - Are the bouncers and/or door persons employees or contract *
- Employees
- Contract
LL - Are guns permitted or kept on premises *
- Yes
- No
LL - Do they allow BYOB or setups *
- Yes
- No
LL - Describe BYOB and/or setups *
LL - Do they have bartenders *
- Yes
- No
LL - Are the bartenders full time and/or part time *
- Part time
- Full time
- Full time and Part time
LL - # of full time *
LL - of part time *
LL - Are all bartenders that serve alcohol certified in a TABC, TIPS, or another type of training course *
- Yes
- No
LL - Within the last 5 years have they been fined or cited for violations related to illegal activities or sale of alcohol *
- Yes
- No
LL - Describe the fines and/or citations in detail *
LL - Have they had any liquor liability claims in the past 5 years *
- Yes
- No
LL - Describe the liquor claim(s) from the past 5 years *
Mobile Home
MH - What is the approximate total acreage of the mobile home park *
MH - Are there any offices, clubhouses, maintenance buildings or any other buildings *
- Yes
- No
MH - # of office buildings: *
MH - of clubhouses *
MH - of maintenance building(s) *
MH - Explain other types of buildings *
MH - Total # of spaces *
MH - What is the approx. % of occupancy *
MH - # of rental mobile home(s) *
MH - Approx. # of occupancy *
MH - Are there any dwelling(s) (excluding mobile homes) *
- Yes
- No
MH - # of dwellings *
MH - Approximate % of occupancy *
MH - Are all roads in good condition *
- Yes
- No
MH: Explain the road conditions. *
MH - Do the roads have any speed control such as speed bumps *
- Yes
- No
MH - Does management allow dogs on the property *
- Yes
- No
MH - Are warning signs posted about dogs on the property *
- Yes
- No
MH - Are permanent mobile homes properly skirted *
- Yes
- No
MH - Are permanent mobile homes properly tied down *
- Yes
- No
MH - Pool on the property *
- Yes
- No
MH - Playground on the property *
- Yes
- No
NightClub / Lounge
NCL - Name of the Nightclub/Bar *
NCL: Is there cooking done on the premises? *
- Yes
- No
NCL: What type of alcoholic beverage license do they have? *
- Beer and Wine
- Liquor
- BYOB
NCL: What is the maximum number of occupancy allowed? *
NCL - Do they have any of these *
- Pool table
- Video games
- Other games
- No games or pool tables
- Live entertainment
- Topless dancers
- Dance floor
- Bouncers or Security guards
NCL: Describe other type of games. *
NCL: Describe the live entertainment. *
NCL: Do they have any special events (wet t-shirt, etc.)? *
- Yes
- No special events
NCL: Describe any/all special events. *
Dance Floor
NCL: Do they have a dance floor? *
- Yes
- No dance floor
NCL: What is the approximate size of the dance floor? *
NCL: What is the surface of the dance floor? *
- Wood
- Concrete
- Vinyl
NCL: Is the dance floor elevated? *
- Yes
- No
NCL: Is there a protective railing around the dance floor? *
- Yes
- No
NCL: Describe the Railing around the dance floor. *
Security Guards and Bouncer Information
NCL - Do they have bouncers or security guards *
- Bouncers
- Security guards
NCL: Are the bouncers employees? *
- Yes
- No
NCL: Are the security guards armed? *
- Yes
- No
NCL: Are the security guards hired or employees? *
- Hired
- Employee
- Hired and Employee
NCL: What is the name of the security agency? *
NCL: Where are the security guards? *
- Inside the Building
- Outside the Building
- Inside and Outside the Building
Nursing home/Assisted living
NH: Do they do any cooking on the premises? *
- Yes
- No
NH: Is the kitchen secure from all patients? *
- Yes
- No
NH: What's the number of patients/clients licensed for? *
NH: What's the current number of patient/clients? *
NH: What's the number of beds? *
NH: What's the percent of occupancy? *
NH: What type of license do they have: *
- Nursing Home
- Assisted Living facility
- Adult Daycare
- Other
- None
NH: Explain other license: *
NH: Are all license current? *
- Yes
- No
NH: What's the number of staff members: *
NH: Are the owners involved in business operations: *
- Yes
- No
NH: Do they have a medical director? *
- Yes
- No
NH: Do all contracted medical personnel have their own professional liability Insurance? *
- Yes
- No
NH: Does insured perform comprehensive background investigation on all perspective staff or contract personnel? *
- Yes
- No
NH: Number of patients/clients that require skilled nursing: *
NH: Does the facility utilize any sub or independent contractors to provide maintenance, housekeeping, or services? *
- Yes
- No
NH: Explain what independent contractors are used: *
NH: Does insured require certificates of insurance on all contractors? *
- Yes
- No
NH: Types of recreation provided: *
- Bingo
- Games
- Stretching and motor control
- None
NH: Are all recreation activities supervised? *
- Yes
- No
NH: How often are fire drills conducted? *
- Monthly
- Quarterly
- None
NH: Is there an emergency evacuation plan and has it been posted throughout the facility? *
- Yes
- No
NH: Does insured administer any medication? *
- Yes
- No
NH: Are all medications administered per the physician's directives? *
- Yes
- No
NH: Are any patient/clients permitted to administer their own medication whether prescription or over the counter? *
- Yes
- No
NH: Are medications kept in a locked cabinet, container or in the refrigerator if needed? *
- Yes
- No
NH: Are records kept on the medications administered? *
- Yes
- No
NH: Are all exterior doors equipped with alarms to prevent wandering of patients? *
- Yes
- No
Play Ground
PG: Are children always supervised when using the playground? *
- Yes
- No
PG: If not supervised, explain how safety is controlled. *
PG: What type of playground surface does the playground have? *
- Grass
- Wood Chips or Mulch
- Earth or Dirt
- Sand
- Rubber
- Other
PG: Explain the other type of surface. *
PG: Is the playground in safe condition? *
- Yes
- No
PG: Explain what is not safe about the playground. *
PG: Is there any hazardous playground equipment such as a trampoline? *
- Yes
- No
PG: Explain the hazardous playground equipment. *
PG: Was all the playground equipment securely anchored? *
- Anchored Properly
- Not anchored
- Not needed
PG: Explain what playground equipment needs to be anchored. *
PG: Is the playground area(s) completely fenced? *
- Yes
- No
PG: Are all entry gates locked to the playground? *
- Yes
- No
POA / HOA
POA: How many members do they have? *
POA: How many lots are in the association? *
POA: What are the number of owners? *
POA: How many homes are in the association? *
POA: Do they have any parks? *
- Yes
- No
POA: Are there any playground(s)? *
- Yes
- No
POA: Do they have a swimming pool(s)? *
- Yes
- No
POA: Are there any lakes, pond, or bodies of water on the property? *
- Yes
- No
POA: Are there any boat ramp, boat slips, or fishing piers in the association? *
- Yes
- No
POA: Are any of the boat ramps, boat slips or fishing piers owned or controlled by the association? *
- Yes
- No
POA: Was there any obvious damage, rust, rotting, or structural problem observed on any structure such as boat ramp, boat slips, or fishing pier? *
- Yes
- No
POA: How many boat ramps? *
POA: Approximately how many boat slips? *
POA: How many fishing piers? *
Roads and Fencing
POA: Are there any public roads or common easements? *
- Yes
- No
POA: Is the association responsible for the maintenance of the public roads or easements? *
- Yes
- No
POA: Describe what type of maintenance the association does. *
POA: What is the condition of the roads and parking areas? *
- Good
- Average
- Fair
- Poor
POA: Is the property completely fenced? *
- Yes
- No
Roof Top
Roof: What was the roof style? *
- Gable Roof
- Hip Roof
- Flat Roof
- Mansard Roof
- Gambrill Roof
- Shed Roof
- Salt Box Roof
- Cross Hipped Roof
- Cross Gabled Roof
Roof: What is the approximate roof slope? *
- Flat Slope 0:12 to 2:12
- Low Slope 2:12 to 4:12
- Conventional Slope 4:12 to 9:12
- Steep Slope over 9:12
Roof: What is the type of roof covering? *
- Composition Asphalt Shingle
- Built up
- Metal
- Rubber Membrane
- Steel
- Tile
- Wood Shake
- Other
Roof: Explain other type of roof covering. *
Roof: Approximately how many years old is the roof cover? *
Roof: Approximately how many years remain on the roof? *
Roof: Have there been any roof overlays? *
- Yes
- No
Roof: What is the number of overlays on the roof? *
- 1
- 2
- 3
- 4
Roof: What is the roof's overall condition? *
- Excellent like new
- Good
- Average
- Fair needs improvement soon
- Curling
- Blistered
- Torn or missing shingles
- Poor needs immediate attention
- Damaged
Roof: Explain poor roof condition. *
Roof: Does the flashing appear to be in good condition? *
- Yes
- No
- No Flashing
Roof: Describe flashing condition: *
Roof: Number of buildings. *
Roof: Total Square footage of buildings. *
Roof: What's the condition on the Drone report. *
- Not attached yet
- Good
- Moderate Damage
- Severe Damage
Swimming Pools
How many pools are there? *
sw: What is the maximum depth of the pool(s)? *
sw: Is the general public ever permitted to use the pool? *
- Yes
- No
sw: Are rules posted in the pool area requiring adult or parental supervision? *
- Yes
- No
sw: Are lifeguards on duty while pool is in use? *
- Yes
- No
sw: Are all lifeguards certified? *
- Yes
- No
SP- Any diving boards or slides *
- Diving board
- Slide
- None
SP- Decks constructed of slip resistant concrete or other materials *
- Yes
- No
sw: Are "NO DIVING" signs displayed in highly visible letters around the pool and/or on the pool deck? *
- Yes
- No
sw: Are depths marked in highly visible letters around the pool on the pool deck and/or edge? *
- Yes
- No
sw: Explain why its not marked or visible. *
sw: Does the pool area have the required life safety equipment visible? *
- Yes
- No
sw: Was there an emergency 911 call phone/device located inside the pool area? *
- Yes
- No
sw: Was there an emergency 911 phone/device located outside the pool area but within 200 feet? *
- Yes
- No
sw: Were signs posted in the pool area advising the location of the emergency 911 phone/device? *
- Yes
- No
sw: Are all lights, outlets and any other electrical components in the pool area protected by a GFCI breaker? *
- Yes
- No
sw: Is there a flotation buoy line or a tile line on the bottom installed across the pool separating the depths over 5 feet? *
- Yes
- No
sw: Does the pool have anti-entrapment drain covers in place compliant with the Virginia Graeme Baker Safety Act? *
- Yes
- No
sw: Are all pool areas fenced? *
- Yes
- No
sw: What is the fence height? *
sw: Are all gates equipped with self-closing and self-latching devices? *
- Yes
- No
sw: Were all self-closing and self-latching devices working properly? *
- Yes
- No
sw: Are all gates locked when the pool is closed or not in use? *
- Yes
- No
sw: Are there any obvious damages or hazards in the pool area? *
- Yes
- No
sw: Explain any pool area damage. *
Cann-General Information
Type of operation? (please check all that apply) *
- Indoor Grower
- Greenhouse Grower
- Outdoor grower no structure
- Extraction
- Processor useable bud only
- Processor bud and more
- Distributor
- Lab or Testing
- Manufacturer
- Retailer or Dispensary
- Medical Dispensary
- Guided marijuana tours
- Recreational
- Other describe
Any IN-HOME cannabis operations ( check all that apply )? *
- Cultivation
- Processing
- Dispensing
- Other describe
- None
ALL required state & local license and permits maintained? *
- Yes
- No
How is insured licensed ? ( city permit # and / or State license # ) *
Ever been denied or suspended licensing? *
- Yes
- No
If Yes, explain: *
IN COMPLIANCE with all local and state LAWs , regarding the cultivation, manufacturing , dispensary &/ or control of marijuana or marijuana-containing products? *
- Yes
- No
If No, FULLY describe: *
Is a MEMBER of any cannabis/marijuana trade associations? *
- Yes
- No
describe members: *
YRS OF EXPERIENCE in Med/Rec Marijuana industry: *
Does insured own any other business? *
- Yes
- No
Is the location FULLY open and operating? *
- Yes
- No
Year business started: *
Hours of operation: *
When is the location expected to be open and fully operational? *
- Month
- Day
- Year
Type of neighborhood: *
- Industrial or Commercial
- Residential
- Rural
No. of Employees at this location? *
Background check for employees? *
- Yes
- No
Does business operate in shifts? *
- Yes
- No
describe ( how many, any night shifts, what kinds of job duties are performed at night?): *
Are volunteers or non-paid workers used? *
- Yes
- No
Are temporary staffing workers or leased employees used? *
- Yes
- No
Is insured a Farm Labor Contractor providing employees to cannabis operations other than cultivation? *
- Yes
- No
Any claims or losses within the past 3 years? *
- Yes
- No
Losses and Claims in past 3 yrs FULL description: *
If Yes, describe: *
Is it a Drug-Free workplace? *
- Yes
- No
Cann-Building / Protection
Building sqft occupied by the insured? *
% of building occupied by the insured? *
Construction type of building: *
- Masonary or Non-Combustible
- Joisted Masonary
- Frame
Year built: *
Is part of the building residential? *
- Yes
- No
Any known building updates: *
- Wiring
- Heating HVAC
- Plumbing
- Roof
- None
Is building sprinkled? *
- Yes
- No
Sprinkler coverage? *
- Full
- Partial
Does the building have an active Central Station Fire Alarm? *
- Yes
- No
Central station burglar alarm? *
- Yes
- No
24/7 interior & exterior video surveillance ( 14 days of recording ) *
- Yes
- No
Motion detectors? *
- Yes
- No
All entryways, doors and windows are locked, secured and protected by alarm during non-business hours. *
- Yes
- No
Buzz-in system at entryway *
- Yes
- No
Hold-up button / Panic button *
- Yes
- No
Security guards on site? *
- Yes
- No
Are they contracted? *
- Yes
- No
Any armed guards? *
- Yes
- No
Are they bonded? *
- Yes
- No
Cann-Retail / Dispensary
EDIBLE - sell/dispense infused medical marijuana edible products containing THC or other active cannabinoid (CBD)? ( e.g. baked goods, candies, other food or drink items, tinctured, capsules, etc.) *
- Yes
- No
If Yes, FULLY describe : *
TOPICAL - sell/dispense topical medical marijuana products containing THC or other active cannabinoids, e.g. oils, creams, lotions, etc. *
- Yes
- No
If Yes, describe : *
VAPORIZERS - sell/dispense medical marijuana oil cartridges or medical marijuana concentrates intended to be used with vaporizers or vapor pens ? *
- Yes
- No
If Yes, describe : *
FDA VIOLATION - sell/distribute or otherwise market cannabis-related products that are in violation of FDA regulations prohibiting the marketing of CBA products claiming the to prevent ,diagnose, t... *
- Yes
- No
If Yes, describe : *
SIGNAGE - If operation is as a retail store or dispensary offering cannabis-related products, is there Signage advertising same ? ( If Yes , provide a photo ) *
- Yes
- No
ANIMAL FOOD - Any sales of animal food or feed to which THC or CBD has been added ? *
- Yes
- No
If Yes, describe : *
DIETARY - Are any THC and CBD marketed , sold &/ or distributed as DIETARY supplements ? *
- Yes
- No
MMIC - Are MEDICINAL products only sold to patients having a current , qualified physician's script or valid medical marijuana identification card ( MMIC ) *
- Yes
- No
MINORS - Is minors access controlled ? *
- Yes
- No
If Yes, describe : *
Room / Lounge - are smoking / vape rooms offered ? *
- Yes
- No
Does all advertising of cannabis-related products contain the required consumption warning ? *
- Yes
- No
Are consumers of the insured's products made aware that edible cannabis can take significantly longer to affect them than other methods of consumption and that just one bite of some edible contains... *
- Yes
- No
Are warnings included stating the potential adverse health effects associated with use of cannabis products containing THC by pregnant of lactating woman ? *
- Yes
- No
Approx. annual receipts ? *
medical marijuana sales / total receipts % *
recreational marijuana / total receipts % *
Average amount of Cash on premise at any given time ? *
Maximum amount of Cash on premise at any given time ? *
Displayed inventory is stored in shatter-proof glass display cases during business hours *
- Yes
- No
What percentage of your stock is kept out of the safe/vault and on display during business hours ? *
- 1-5
- 6-10
- 11-15
- 16-20
- 21-25
Is the grow facility located in the same building as a dispensary ? *
- Yes
- No
describe grow facility location : *
Cann-Delivery / Distribution (testing labs, warehouse)
Is delivery service offered ? *
- Yes
- No
Is delivery done by employees or is this contracted ? *
- Employees
- Contracted
Average trip distance of delivery ? *
Typically, how many deliveries per week ? *
Does insured own or lease vehicles ? *
- Own
- Rent
- Lease
- Borrow
- Other describe
Is there a Warehouse for storage of products ? *
- Yes
- No
describe warehouse location : *
If offering guided marijuana tours, describe , including number, type of vehicles and how many passengers ? *
Cann-Guided Tour
Are there separate a/c and air filtration systems for the driver and passenger cabins and with no air flow between the cabins ? *
- Yes
- No
If guided marijuana tours are offered , is there partition/eisen-type glass ( e.g. Strataglass) between the driver and passenger cabins ? *
- Yes
- No
If any delivery of cannabis & ? or guided marijuana tours , are drivers checked for not being impaired i.e. under the influence ? *
- Yes
- No
How is smoke prevented from leaking through to the driver ? *
- Yes
- No
Does insured use a separate entity to transport the plants ? *
- Yes
- No
describe transportation methods : *
Does insured process the plants to finished products? *
- Yes
- No
Type of Lighting: *
- Fluorescent Grow Light
- High Intensity Discharge grow light HID
- LED grow light
Are any metal halide bulbs used in HPS ballast ? *
- Yes
- No
Any use of metal halide and HPS bulbs interchangeably in light fixtures? *
- Yes
- No
Cann-Processing / Extraction
How are the buds trimmed? *
- Wet
- Dry
- machine
- hand
What is the extraction solvent used ? *
- ACETONE
- ALCOHOL ETHANOL
- BUTANE
- CO2
- HEXANE
- ISOPROPYL ALCOHOL
- METHANOL
- Oil or Fat
- PROPANE
- TOLUENE
- WATER
- OTHER
Extraction system used *
- Closed loop
- Open ended loop
Do you have the material safety data sheets ( MSDS) for the chemicals used ? *
- Yes
- No
For other than approved , unattended processes, is the extraction process continuously staffed ? *
- Yes
- No
17. Is all monitoring of the extraction process by staff who are adequately trained in the extraction process and all emergency procedures ? *
- Yes
- No
All extraction work carried out in class 1 D 1 room , if using volatile solvents *
- Yes
- No
Is the extraction room free of not-in-use LPG containers ? *
- Yes
- No
All flammables are stored in a UL listed cabinets *
- Yes
- No
Fume hood ? *
- Yes
- No
Automatic exhaust ventilation system ? *
- Yes
- No
Explosion proof electrical ? *
- Yes
- No
Automatic gas detection system in place ? *
- Yes
- No
What type( s) of equipment are used for post-processing and winterization (i.e. the removal of fats) involving the heating or processing of the raw extract ? *
15. Is all equipment used for the extraction of oils from plant material listed and approved for the specific use ? *
- Yes
- No
Manufactures and model of extraction equipment : *
All utensils used in extraction process are Non-sparkling *
- Yes
- No
Is testing performed on site ? *
- Yes
- No
describe testing process ( specifically list any chemicals or solvents that may be used ) *
What type of extraction system ? *
- Closed loop
- Open ended loop
What is the quality of Eisen glass ? *
what is the strength of the Eisen glass ? *
Cann-Special Hazards & Controls
10a. Do the cooling and heating power of the temperature control units (TCUs) meet the capacity requirements for the size of the application ? *
- Yes
- No
Opinion of Risk : *
- Excellent
- Good
- Good but with Property or Liability recommendations noted

Active fields on your form can be edited in the box below.

Form Properties

Title
Theme
Notification Email
Confirmation Msg	Thank you for filling this form

Field Properties -

Text
Label
Max Characters
Required
Hide Control
Control Action
Options
Selected Option
Hint
Property Lens
Valid Extensions
Max. File size (kb)
Min. File size (kb)
Help Text
Recommendations

Basic Tools

Advanced Tools

Package Add-on

Supplement forms

Apartment Form

BBQ Pit

Builders Risk

Convenience Store

COOKING FORM 1

Give a percentage breakdown of the receipts

Give a breakdown of the cooking equipment.

Vent Hood Exhaust System

AES Automatic Extinguishing System

Cooking Form 2

Cooking Form 3

Cooking Form 4

Cooking Form 5

Cooking Form 6

Daycare

Duplex / Triplex

Food Storage / Sanitation

Hotel/Motel

Gross Receipts

Room Rentals

Security Information

Inland Marine

Equipment Information

Laundry / Dry cleaner

Liquor Liability

Provide breakdown of receipts for each that apply include a 0 for none.

Mobile Home

NightClub / Lounge

Dance Floor

Security Guards and Bouncer Information

Nursing home/Assisted living

Play Ground

POA / HOA

Roads and Fencing

Roof Top

Swimming Pools

Cann-General Information

Cann-Building / Protection

Cann-Retail / Dispensary

Cann-Delivery / Distribution (testing labs, warehouse)

Cann-Guided Tour

Cann-Processing / Extraction

Cann-Special Hazards & Controls

Form Properties

Field Properties -