Package Report - Drag N' Drop FormBuilder

Package Report

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? *
- Less than 1
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- Over 10

occ34- Insured's time at this location? *
- Less than 1
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- Over 10

occ35- # of locations *
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- Over 20

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 *

Contents

occ44- Owner contents in the building, (You must verify) *
- Owner has contents
- Owner has NO contents

occ45- Describe the building owner's contents *

occ46- Owner content value? *

occ47- Tenant contents in the building. (You must verify) *
- Tenant has contents
- Tenant has NO contents

occ48- Describe the tenants contents *

occ49- Tenant content value? *

occ51- Additional notes: *

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? *
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- Over 10

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? *
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- 60
- 65
- 70
- 75
- 80
- 85
- 90
- 95
- 100

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) *
- Federal Pacific/Stab-Lok
- Zinsco panel
- GTE-Sylvania
- Challenger
- General Electric
- Square D (Built between 2020 and 2022)
- Square D
- Cutler Hammer
- Siemens
- Eaton
- Schneider
- Westinghouse
- Other Brand
- Label not visible
- Electrical panel not accessible
- Fuse panel

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 *
- Central Electric
- Central gas
- Window Units
- Thru Wall Units
- Wall furnace electric
- Wall furnace gas
- Space heater electric
- Space heater gas
- Wood stove
- None observed

Years since last hvac updates *
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- Over 30
- Over 40
- Done as needed
- Unknown to insured

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 *

INSERT FORM: BUILDING 1,2,3,etc. Here (delete)