Agricultural Facility Report - Drag N' Drop FormBuilder

Agricultural Facility Report

General

Date of Inspection: *
- Month
- Day
- Year

Name of Person Interviewed: *

Title of Person Interviewed: *
- Insured
- General Manager
- Property Manager
- Building Super
- Tenant (other than the Insured)
- Other Title

List Other Title: *

Total number of buildings at location: *

Buildings present at this location: (Check ALL that apply) (If add'l bldgs are needed use the Agricultural Facility Extra Bldgs form) *
- Cotton Warehouse Building
- Cotton Warehouse Building 02
- Cotton Warehouse Building 03
- Cotton Warehouse Building 04
- Cotton Warehouse Building 05
- Cotton Warehouse Building 06
- Cotton Warehouse Building 07
- Cotton Warehouse Building 08
- Cotton Warehouse Building 09
- Cotton Warehouse Building 10
- Cotton Warehouse Building 11
- Cotton Warehouse Building 12
- Cotton Warehouse Building 13
- Cotton Warehouse Building 14
- Cotton Warehouse Building 15
- Office Building
- Shop Building
- Seed Storage Building
- Gin Processing Building
- Equipment Storage Building
- Chemical Building
- Fertilizer Building
- Other Building
- Other Building 2
- Other Building 3
- Other Building 4
- Other Building 5
- Other Building 6
- Other Building 7
- Other Building 8
- Other Building 9
- Other Building 10

Name the Other Building using its Description/Occupancy: *

Name the Other Building 2 using its Description/Occupancy: *

Name the Other Building 3 using its Description/Occupancy: *

Name the Other Building 4 using its Description/Occupancy: *

Name the Other Building 5 using its Description/Occupancy: *

Name the Other Building 6 using its Description/Occupancy: *

Name the Other Building 7 using its Description/Occupancy: *

Name the Other Building 8 using its Description/Occupancy: *

Name the Other Building 9 using its Description/Occupancy: *

Name the Other Building 10 using its Description/Occupancy: *

What is the maximum number of cotton bales that can be stored in the Largest warehouse building? *

Per Bale Value: (Currently $500) *

Cotton Stock PML (Probable Maximum Loss) in dollars *

General Comments: *

Losses

Are there prior losses? *
- Yes
- No

Describe prior losses; loss trends; status of repairs; and any corrective measures to prevent further loss. *

Operations

How long has the Insured been in business? *

How many years of experience does the owner/manger have in this industry? *

Building Interest: *
- Owned
- Leased

Number of Employees: *

Hours of Operation: *

Besides the Insured, are there any other occupants or operations? *
- Yes
- No

List each occupant: *

Does the Insured own any of the cotton bales stored at this location? *
- Yes
- No

Percentage of stored cotton bales that are owned by the insured: *

Operations Comments: (Include a description of the operations at this location) *

Office Building
NOTE: Questions in this section ONLY apply to the Office Building. If Office Building was not checked above, this section will be blank.

*
- OFFICE BUILDING

Occupancies in this building: *
- Main Operations Office
- Other

List Other occupancy: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Office Building Comments: *

Shop Building
NOTE: Questions in this section ONLY apply to the Shop Building. If Shop Building was not checked above, this section will be blank.

*
- SHOP BUILDING

Occupancies in this building: *
- Shop
- Main Operations Office
- Other

List Other occupancy: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Shop Building Comments: *

Equipment Storage Building
NOTE: Questions in this section ONLY apply to the Equipment Storage Building. If Equipment Storage Building was not checked above, this section will be blank.

*
- EQUIPMENT STORAGE BUILDING

Occupancies in this building: *
- Equipment Storage
- Main Operations Office
- Other

List Other occupancy: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Please list the equipment stored within this building: *

Equipment Storage Building Comments: *

Seed Storage Building
NOTE: Questions in this section ONLY apply to the Seed Storage Building. If Seed Storage Building was not checked above, this section will be blank.

*
- SEED STORAGE BUILDING

Occupancies in this building: *
- Seed Storage
- Main Operations Office
- Other

List Other occupancy: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *
EXTINGUISHERS

Are there an adequate number of Fire Extinguishers provided? *
- Yes
- No

Extinguisher Service Tags: *
- Current (within 1 year)
- Expired (Over 1 year)
- No Tags

Extinguisher Tag Date: *
- Month
- Day
- Year

Properly Mounted: *
- Yes
- No

Describe Extinguisher Deficiencies: *

Posted No Smoking Signs? *
- Yes
- No

Seed Storage Building Comments: *

Gin Processing Building
NOTE: Questions in this section ONLY apply to the Gin Processing Building. If Gin Processing Building was not checked above, this section will be blank.

*
- GIN PROCESSING BUILDING

Occupancies in this building: *
- Gin Processing
- Main Operations Office
- Other

List Other occupancy: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Is the Ginning equipment well maintained and in good condition? *
- Yes
- No

Describe condition or maintenance issues with the gin equipment : *
Note: You must take a clear photo of any ginning equipment present.

FIRE SUPPRESSION

Is the Gin equipment protected by an automatic fire suppression system? *
- Yes
- No

Suppresion System Service Tags: *
- Current (within 1 year)
- Expired (Over 1 year)
- No Tags

Service Tag Date: *
- Month
- Day
- Year

Service Company: *
EXTINGUISHERS

Are there an adequate number of Fire Extinguishers provided? *
- Yes
- No

Extinguisher Service Tags: *
- Current (within 1 year)
- Expired (Over 1 year)
- No Tags

Extinguisher Tag Date: *
- Month
- Day
- Year

Properly Mounted: *
- Yes
- No

Describe Extinguisher Deficiencies: *
QUARANTINE

Describe the quarantine room and quarantine practices. You must include the following: Where is the quarantine room? After a fire in the Gin, how many bales are quarantined? How long is the quarant... *

Posted No Smoking Signs? *
- Yes
- No

Gin Processing Building Comments: *

Chemical Building
NOTE: Questions in this section ONLY apply to the Chemical Building. If Chemical Building was not checked above, this section will be blank.

*
- CHEMICAL BUILDING

Occupancies in this building: *
- Chemicals
- Main Operations Office
- Other

List Other occupancy: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Chemical Building Comments: *

Fertilizer Building
NOTE: Questions in this section ONLY apply to the Fertilizer Building. If Fertilizer Building was not checked above, this section will be blank.

*
- FERTILIZER BUILDING

Occupancies in this building: *
- Feritilizer
- Main Operations Office
- Other

List Other occupancy: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Fertilizer Building Comments: (include how much fertilizer is stored here) *

Other Building
NOTE: Questions in this section ONLY apply to the Other Building you described earlier. If Other Building was not checked above, this section will be blank.

List the Occupancies: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Other Building Comments: (What is this bldg used for, list what is stored, and how much. Also indicate the type of fire protection and whether it is properly maintained.) *

Other Building 2
NOTE: Questions in this section ONLY apply to the Other Building 2. If Other Building 2 was not checked above, this section will be blank.

List the Occupancies: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Other Building Comments: (What is this bldg used for, list what is stored, and how much. Also indicate the type of fire protection and whether it is properly maintained.) *

Other Building 3
NOTE: Questions in this section ONLY apply to the Other Building 3. If Other Building 3 was not checked above, this section will be blank.

List the Occupancies: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Other Building Comments: (What is this bldg used for, list what is stored, and how much. Also indicate the type of fire protection and whether it is properly maintained.) *

Other Building 4
NOTE: Questions in this section ONLY apply to the Other Building 4. If Other Building 4 was not checked above, this section will be blank.

List the Occupancies: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Other Building Comments: (What is this bldg used for, list what is stored, and how much. Also indicate the type of fire protection and whether it is properly maintained.) *

Other Building 5
NOTE: Questions in this section ONLY apply to the Other Building 5. If Other Building 5 was not checked above, this section will be blank.

List the Occupancies: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Other Building Comments: (What is this bldg used for, list what is stored, and how much. Also indicate the type of fire protection and whether it is properly maintained.) *

Other Building 6
NOTE: Questions in this section ONLY apply to the Other Building 6. If Other Building 6 was not checked above, this section will be blank.

List the Occupancies: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Other Building Comments: (What is this bldg used for, list what is stored, and how much. Also indicate the type of fire protection and whether it is properly maintained.) *

Other Building 7
NOTE: Questions in this section ONLY apply to the Other Building 7. If Other Building 7 was not checked above, this section will be blank.

List the Occupancies: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Other Building Comments: (What is this bldg used for, list what is stored, and how much. Also indicate the type of fire protection and whether it is properly maintained.) *

Other Building 8
NOTE: Questions in this section ONLY apply to the Other Building 8. If Other Building 8 was not checked above, this section will be blank.

List the Occupancies: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Other Building Comments: (What is this bldg used for, list what is stored, and how much. Also indicate the type of fire protection and whether it is properly maintained.) *

Other Building 9
NOTE: Questions in this section ONLY apply to the Other Building 9. If Other Building 9 was not checked above, this section will be blank.

List the Occupancies: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Other Building Comments: (What is this bldg used for, list what is stored, and how much. Also indicate the type of fire protection and whether it is properly maintained.) *

Other Building 10
NOTE: Questions in this section ONLY apply to the Other Building 10. If Other Building 10 was not checked above, this section will be blank.

List the Occupancies: *

Building Construction: *
- Frame/Combustible
- Joisted Masonry
- Non-Combustible
- Masonry Non-Combustible
- Modified Fire Resistive
- Fire Resistive

If mixed construction, list the percentage of each type: *

Year Built: *

Number of Stories: *

Building Square Footage: *

Is the building in good condition? *
- Yes
- No

Describe condition concerns: *

Other Building Comments: (What is this bldg used for, list what is stored, and how much. Also indicate the type of fire protection and whether it is properly maintained.) *